the uterus, if recognized, predispose to perforation during the course of intra-uterine maneuvers.

Malposed uteri are most frequently perforated opposite the point of angulation.

5. Get a mental picture, as clear as possible, of the pelvic organs. Having a definite mind picture of the pelvic conditions existing in the individual case, if a uterine perforation occurs, it is more immediately recognized and one desists from further intra-uterine instrumentation. For instance, suppose that in a given case the uterus has, by examination, been determined to be normal in size, in volume, and in position, and that during the introduction of the uterine instrument, the latter slips much to one side of the median line and to a depth greater than that of the uterine cavity, perforation will then immediately be diagnosed.

6. Observe the most rigid asepsis during the course of the operation and see that from the standpoint of asepsis and antisepsis, the patient has ben prepared as carefully as though you were going to perform a laparotomy. A complication, necessitating a laparotomy, may suddenly arise. Not much can be done to cure existing infection. Much can be done to prevent the occurrence of infection. The endometrium sits directly on the myometrium without an intervening sub-mucosa, to check endometrial infectious invasion.

Chief amongst the pathological states that predispose to the occurrence of perforating wounds of the uterus are the following. The changes (hyperemia, softening, etc.) present in menstruating, in pregnant, in puerperal and in post-abortum uteri. Perforation is favored by the peculiar state of the muscular tissue of the puerperal uterus. In curetting congested, softened uteri, such as are met after abortion, and after child-birth, no attempt should be made to elicit the uterine "cry", that is, the peculiar creaking noise, due to the forcible scraping of the uterine wall by the curette. In these cases, owing to the softness and friability of the uterine wall, this sound. is not obtainable.

All the different forms of uterine atrophy, of themselves cause a weakening of the uterine wall, and therefore can be looked upon as conditions predisposing to uterine perforation. Atrophy of the uterus has been observed in some chronic diseases; as in pulmonary tuberculosis, occasionally in diabetes, in leukemia, in chlorosis, in pernicious anemia, in Addison's disease, in Basedow's disease, etc. It is stated that also in certain acute infectious diseases such as typhoid fever, a marked atrophy of the muscular tissues is noted.

Inflammatory processes of the uterine tissues may be localized; may be diffuse. Like inflammatory processes elsewhere, they are destructive in nature. Whatever be the nature of the inflammation, acute or chronic, or the site, be it located in the mucosa, in the muscularis or in the connective tissues, it invariably weakens the resistance of the uterine wall.

Prolonged septic processes predispose to uterine perforation. Tubercular uterine inflammation by leading to abscess, to cavity formation, can of itself cause uterine perforation.

Inflammation of the uterus may terminate in resolution, in ulceration, in suppuration, or in gangrene. The occurrence of abscess of the uterus is no longer contested, as many of the cases reported. have been amply verified. Uterine abscesses may be acute, subacute, or chronic; may be primary or secondary; in the primary form, the pus collection has its starting point as such in the uterine tissues; in the secondary form, the suppurative process starts in neighboring tissues and invades the uterus by extension through continguity. In the first form, at the beginning, if not throughout its entire course, the pus collection is entirely circumscribed by uterine tissue; in the secondary form, it is partly surrounded by the uterine tissue, partly by other tissue.

In number, these abscesses may be single, may be multiple. In location, they are either submucous, intra-muscular or interstitial, or sub-peritoneal. Their site may be in the anterior wall; may be in the posterior wall. Uterine abscesses are always due to infection; a pathological, surgical, or traumatic solution of surface continuity of the uterine mucosa serving most frequently as the portal of infection. Any pyogenic organism, facultatively or habitually so, can be the causative germ. Tubercular abscesses have been reported. Nevertheless, the ordinary pyogenic cocci are the most frequent offenders. The germs are either implanted in the uterine tissues by a vulnerating instrument, or may be conveyed to the site of abscess development by the lymphatic vessels. Rarely the abscess is embolic. abscess may be secondary by contiguity of tissues to an infective uterine thrombo-phlebitis. The liability to the latter, (septic thrombophlebitis) occurrence during the post-abortum period is well known.

The

All uterine abscesses impair the solidity of the uterine wall. They predispose to traumatic perforations, as the abscess site forms a circumscribed area of lessened resistance. They may rupture spontaneously into the rectum, into the bladder, into the uterine cavity, into the peritoneal cavity, etc. They may give rise to spon

taneous perforations, as when the abscess ruptures both into the uterine cavity and into an adjacent cavity or space.

Another possible termination of uterine inflammation, which predisposes to perforation, is gangrene. Uterine gangrene may be circumscribed, may be general, may involve the entire thickness of the uterine wall, may only involve a part of its thickness; may be due to traumatic, inflammatory neoplastic, or to chemical causes. It may

be secondary to criminal or other intra-uterine maneuvers; it may be spontaneous. Cases of gangrene, due to contact of caustics with. the uterine wall, are reported.

Gangrenous metritis is a condition which predisposes to traumatic uterine perforation; which may result in spontaneous perforation.

It may be partial, it may be total, it may be perforating.

On examining the organ, it is at times difficult to determine if the perforation is secondary to the gangrene, or, if the gangrene is secondary to an inflammation, started by an instrument which has penetrated the uterine wall. The inflammatory gangrene enlarges the traumatic lesion and may lead one to think that the perforation is spontaneous in origin.

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CONCLUSIONS.

1. Pseudo-perforation of the uterus, though of exceptional occurrence is a condition that occasionally confronts the surgeon.

2. Spontaneous perforations of the uterus, due to pre-existing pathological conditions of this organ can and do occur.

3. Perforating wounds of the uterus, be they intra-peritoneal or extra-peritoneal, have a morbidity, have a mortality. This morbidity, this mortality, increases in direct ratio with the inexperience, the carelessness, the surgical uncleanliness of the operator. The expert recognizes at once the making of a false passage and institutes proper treatment. High surgical skill may convert an apparently hopeless case into a recovery.

4. Dilatation of the cervical canal, and instrumental curettage of the uterine cavity are, owing to their associated dangers, not office operations. During the performance of either of these two apparently danger-free operations, the operator may be confronted by accidents, the meeting of which requires the highest surgical skill. In their performance, if an anesthetist be available, the employment of general anesthesia (in the absence of contra-indications) is highly desirable, in fact, the rules should be:

a. No uterine curettage without general surgical anesthesia. It is easy to conceive how an unanesthetized patient can, by injudicious jerks or movements, perforate her own uterus, by impaling it, by spiking it upon the intra-uterine instrument. Anesthesia permits the operator to depress the abdominal wall, to locate, to fix, if necessary, the fundus uteri.

b. No curettage without ample cervical dilatation. A non-dilated cervical canal interferes with the tactile sense and thereby with the proper maneuvering of intra-uterine instruments. Steady the cervix, before beginning the dilatation of the canal.

6. Intra-uterine instrumental maneuvers should only be attempted by those:

a. Who are thoroughly conversant with modern surgical asepsis and antisepsis. The absence of bacteria on the perforating instrument minimizes very much the dangers of perforation. Infection has immediate, has late dangers. In an uncomplicated perforating wound of the uterus, the traumatism of the uterus plays but a secondary role; the pre-existence, or the implantation, at the time or subsequently, of infection commands the situation.

b. Who are capable of recognizing malpositions of the uterus as well as pathological conditions of that and of neighboring organs. Even the bringing of the cervix to the vulva and outlet may disturb peritoneal adhesions, may rupture pus pockets.

C. Who are acquainted with the dangers incident to the successive steps of the intra-uterine operation, which they are performing. The steel dilator is an instrument of too much power, and the curette is too dangerous a weapon to be used by the novice.

7. Once the uterus is perforated, all further instrumentation must be suspended. If it be imperative that the contents of the uterine cavity be removed, this must be done by digital curettage, or it may be done with a curette, whilst the uterus is being watched from above, through a laparotomy incision.

8. A perforated uterus should never be mopped or swabbed with caustics or irritating antiseptics.

9. A perforated uterus should never be irrigated. In 17 cases in which it is stated that the uterus was irrigated during the course of perforation or afterwards, there were 6 recoveries. The great danger attending intra-uterine irrigation in these cases is the conveyance, the diffusion by the irrigating fluid of septic material from the uterine into the peritoneal cavity or other space. Owing to the great absorptive power of the peritoneum, the danger of chemical intoxication is also present.

10. If the perforated wound has been inflicted upon a non-septic uterus during the course of an aseptic intra-uterine maneuver, in the absence of complicating abdominal lesions, recovery is the rule.

11. The treatment of perforating wounds of the uterus is determined largely by the following conditions:

a. The septicity or asepticity of the uterus and its contents. b. The septicity or asepticity of the perforating instrument. C. The presence or absence of co-existing vascular, omental, or intestinal lesions.

d. The size and the number of the perforations. A piece of omentum may prolapse through a large rent. A coil of gut may become incarcerated or strangulated in a large perforation.

a. If the uterus be non-septic, if the perforating instrument be aseptic, and if it can also be reasonably assumed that there is an absence of omental or intestinal or important vascular lesions, the treatment to be followed is one of "armed expectancy." The patient must be confined to bed and immobilization enjoined for at least three days. The patient's pulse, temperature, facies and abdomen must be carefully watched. A suppurative cellulitis, signs of internal hemorrhage, etc., call for intervention. A wick of gauze may be inserted into the uterus, but it should not be introduced much beyond the internal os.

b. In all cases in which there has been a prolapse of the omentum, or of intestines into the uterine cavity; in all cases in which associated injuries to the intestines or omentum co-exist, or in which there are reasons to fear a significant internal hemorrhage, laparotomy is urgent.

C. Once the abdominal wall has been opened the visceral lesion must be repaired. The uterine puncture, if small, need not be sutured. If large (when the perforation is large you cannot depend upon the contractility of the uterine muscle, to entirely occlude it): if of the nature of a tear, of a laceration, it is better that it be sutured. One or two layers of sutures may be used. Whether small or large, if the perforation be the seat of hemorrhage suturing is indicated. Some clinicians teach that every perforating wound of the uterus calls for a laparotomy. They base their teaching upon the following consideration:

a. That the exact size of the perforation is not known.

b. That hemorrhage may be taking place from the peritoneal surface of the wound.