aborted. Her family physician, a man of excellent general ability, was called, as the woman was flowing. Her doctor first tried to empty the uterus without an anesthetic, but could not finish on account of pain. Next day, under chloroform, he proceeded to finish the operation. A Goodell dilator was introduced into the patulous cervix and the blades separated. A placental forceps was then introduced, presumably into the uterine cavity, and something which was felt was pulled down. This proved to be small intestine, whereupon the same was hastily replaced and the vagina packed with iodoform gauze. The author saw the patient several hours later in consultation, and had her taken at once to the hospital. Her condition was fair; there was little shock; she looked somewhat pale and anxious. Pulse 120, temperature 101°. Abdomen flat, soft and not tympanitic; slight tenderness over lower portion. No vomiting and little pain. She was prepared for laparotomy, and the abdomen was opened about seven hours after the accident. A few clots of blood were sponged out of lower abdomen but there was no free fecal matter. The bowels were fortunately empty. On pulling up the coils lying in pelvis they were seen to be detached from the mesentery for a considerable distance. The bowel itself was uninjured except for slight bruised areas here and there. One portion of bowel was seen to enter a rent in the anterior surface of uterus, whence it was easily pulled out. The mesentery showed no bleeding, although large arteries and veins had been torn across. The gut was torn away at its mesenteric attachment, no portion of the mesentery adhering to the bowel.

There being no other injuries, a resection of the injured portion was made and an end-to-end anastomosis done with a Murphy button. The free edge of mesentery was sutured with a running catgut suture. Four feet of bowel was removed.

The uterus was retroflexed, somewhat enlarged and firm in consistency. On its anterior surface was a transverse slit which led diagonally through the wall terminating at point of angulation. It was large enough to admit the finger. The uterine cavity was empty. The perforation was sutured with interrupted catgut and the abdomen closed without drainage.

Subsequent History. The patient made an uneventful recovery. Wound healed by primary union. Button passed on the tenth day. No further uterine symptoms, and at this writing the patient is quite well.

Remarks. The perforation was due, not to any abnormal soft

ening of the uterus, but to a failure to appreciate beforehand the direction of the uterine canal. The uterus being retroflexed, the dilators, with their curved points, were introduced, under the impression that the fundus was forward. Hence the piercing of the anterior wall at point of angulation.

In the second place the placental forceps was used and something was grasped in the dark without it being known what was in the hold of the instrument. The gut, on being pulled through the false passage, was stripped from its mesentery. The arteries and veins, owing to their severance by torsion, did not bleed, beautifully illustrating this long-known surgical phenomenon.

cases.

Is there such a thing as temporary paralysis of the uterus?— If, while passing a sound into the uterine cavity, the instrument slips to an abnormal depth-slips away into unresisting spacedoes that mean a perforation? It is always with a sense of relief that one feels resistence on passing sounds in a certain class of Beuttner reported some cases where after distinctly palpating the somewhat enlarged uterus, he then passed a sound which entered 13 to 20 cm. This phenomenon he tried to explain on the hypothesis of a temporary paralysis or "ballooning" of the uterus, due to mechanical stimulation. In the absence of ocular demonstration, his views were generally contested, and his cases considered as probably perforations.

Kossmann, before curetting, passed a sound with extreme care; it slipped in to 14 cm. After a short time the canal measured. 7 cm., whereupon he proceeded with the operation and felt the uterus to be firm and contracted. Kossmann believes the case to have been one of temporary paralysis of the uterine wall. It is more within the realm of experience, however, to consider such cases perforations.

Can the Fallopian tubes be probed in the normal subject?— Probably not; but the presence of tumors or other morbid conditions may render them permeable to a sound. Thorn experimented on specimens removed by operation and on the cadaver. He was unable to pass even a fine probe into the tube in cases of approximately normal uteri. He regards doubtfully the claims of those who report having passed probes on the living. Generally the cases were perforations.

The cases of Bischoff and Floeckinger are the only ones on record, according to Thorn, in which a sound was passed into a tube and demonstrated to be there by immediate operation. Both cases were myomatous uteri.

It is safe to assume then that when a sound passes to an abnormal depth in a uterus palpably of about normal size, that it is a case of perforation.

Factors Predisposing to Perforation.-These are conditions general or local, which have as a result the atrophy and softening of the uterus.

Döderlein, in his chapter on "Atrophia Uteri" in Veits' Handbuch der Gynäkologie, p. 390, agrees with Thorn in classifying atrophy into (a) Physiological, and (b) Pathological. The former includes lactation atrophy, senile and post-operative atrophy; but as these are mostly concentric with firm walls, the organ is rarely the seat of perforation.

The pathological variety of atrophy may be (a) puerperal, or (b) non-puerperal. It is in cases of puerperal atrophy that the accident of perforation has most frequently occurred. The prime factor in this form of atrophy is "infection."

Dittrich has demonstrated in cases of puerperal septic metritis the presence of hyaline degeneration, fatty degeneration and necrosis of muscle fiber.

Döderlein mentions cases of excentric atrophy in which the uterine canal is longer, but the wall very thin and friable. Such a uterus is usually retroflexed and very difficult of palpation. On passing a sound the instrument is liable to pass through the wall in spite of care.

Schulze-Villinghausen had two such cases occurring in weak, poorly nourished women, who had undergone numerous pregnancies and abortions. The uteri were large and soft. When the sound was passed, it simply, went through the wall without any resistance being offered. The experiment was repeated and a vaginal hysterectomy done in both cases. Careful microscopic examination was made and can be read in detail in the original. The main points were the absence of fatty degeneration of muscle fiber; the separation of the muscle by an edematous infiltration; the great increase of blood-vessels with thickened walls, and the absence of inflammation.

Glaeser reports a somewhat similar case where the sound passed through of its own weight. After a vaginal hysterectomy the fundus was seen to be very thin and soft, or, as described by Glaeser, "wie gäusefett" (goose fat).

The studies of Ries on post-puerperal atrophy of the uterus have shown that the wall may be of extreme thinness, and the mucosa partially or entirely gone. In extreme cases the wall may

in places consist only of thrombosed vessels, the muscle fibers having disappeared through fatty necrosis. This type is the socalled "uterus membranaceus."

Kentman reports a case of myometritis edematosa, in which he discovered that he had perforated and performed a vaginal hysterectomy. Microscopically the muscle fibers were separated from each other by large interspaces, which were filled by a hyaline exudate. The vessel walls were thickened and the muscle fibers degenerated.

Bacon and Herzog report the findings of a case which terminated fatally soon after curettement. There had been a chronic infection lasting for months. The uterus was highly degenerated and showed areas of necrosis.

Dupuy speaks of cases where the uterus was so friable that instruments passed through with the utmost ease.

Among the local conditions which may be associated with uterine atrophy and softening are carcinoma, myoma, pelvic tuberculosis, pelvic abscess, etc.

Such general diseases as leukemia, diabetes, nephritis, Addison's disease, tuberculosis, pernicious anemia, may, along with the general wasting, be accompanied by uterine atrophy.

Gottschalk reports atrophy after acute infectious diseases, viz.: scarlet fever, typhoid fever and articular rheumatism.

Polak had a case in which the woman had a laparotomy some years before. There was a purulent discharge. Uterus perforated with Goodell dilators; immediate laparotomy. At the point of perforation the uterine wall was softened by suppuration due to the working through of some heavy silk. Opening sutured and recovery.

Is the Operator Blamable if He Perforates the Uterus?-This is an important question from a medico-legal standpoint, and one whose decision must be based on all the attending facts and circumstances. Mention has already been made of that class of soft uteri which offer absolutely no resistence to any instrument. The most expert operator will perforate, but will at once recognize the condition and act accordingly (Brothers, Alt, Liebman, Zinke, Queisner, Schulze-Vellinghausen, Kelly, von Herff, and others). The novice, however, will remain in the dark as to the situation, and will persist in curetting and pulling down things with the placental forceps.

In the former event the operator should not be held liable, even in the case of a fatal outcome; the accident was clearly not due

to negligence or want of proper knowledge and skill. In the second case, however, there might be a question as to the liability, owing to a failure to recognize the perforation and the infliction of fatal visceral injuries.

In the Berliner Klin. Wochenschrift, 1886, July 5, p. 452, is related the experience of a young Berlin doctor who curetted for abortion and injected liquor ferri. The woman died; at autopsy four perforations were found. In spite of the expert testimony in his favor by Prof. Gusserow, the doctor was condemned to two months' imprisonment.

Von Herff, commenting on this case shortly after, warns against being too hasty in condemning a brother physician in whose hands such an accident has occurred. He cites a case of his own where there was hemorrhage after abortion, and a large, soft uterus. Using the utmost care, and thinking of perforation, the sound suddenly slipped through the wall of the uterus. All manipulations stopped. No sequelae. In a few days he was able

to curette.

Landau was called to testify in two cases where the uterus had been perforated; once for an incomplete abortion, and once for gonorrheal endometritis. The patients died, but Landau testified that the doctors were not criminally negligent, as they exercised reasonable care, and they were acquitted.

In the case of Bacon and Herzog the accused doctor was acquitted, it being shown that there were present such extensive degenerative changes in the uterus that the perforation was not due to negligence.

Cassatt (quoted by Pichevin) tells of a case where the operator perforated the uterus and introduced his curette so far that he actually lost it in the peritoneal cavity. It was eventually recovered with long forceps.

Mechanism of Perforation.-The perforation is accomplished either with a probe, sounds, curette, douche point, dilators, sponge tent, or other instrument.

The probe makes a clean, smooth puncture, depending somewhat on the character of the uterus. No intestinal injury has ever been reported following its use.

The curette naturally makes a larger hole, either from being pushed through or a portion of the wall being scraped away (Zinke). The bowel has been injured by the curette.

Sounds, such as Hegar's dilators, may perforate like a probe, only making a larger opening.