of the motor nerves directly-the irritability of the motor nerves is not destroyed. The sensory nerves are either unaffected, or their irritability increased. The reflex functions of the spinal cord are exalted. The different nerves preserve their irritability and communicate impressions to the reflex centers. Motor impulses are quickly originated and the muscles through the motor nerves are fixed in a state of tonic contraction. The effects of strychnia is not limited to the central portion of the nervous system, but extends to the sympathetic, indicated by dilation of the pupils, erection of the hair follicles and tinnitus. The increased heat of the limbs indicates an influence on the sympathetic system similar in kind to that exerted in the voluntary. A very considerable rise in the arterial pressure, and contraction of the vessels of the frog's web, caused by strychnia, has been experimentally demonstrated every year in our own laboratory.

The remarkable similarity in the symptomology of traumatic tetanus and strychnia tetanus require that the points of difference between them be clearly set forth. In strychnia tetanus the jaw muscles are not first thrown into spasms and are not always rigid during the paroxysm; in traumatic tetanus trismus is one of the first symptoms. In strychnia tetanus after the convulsion lasting from a half to one or two minutes, there is usually complete relaxation; in traumatic tetanus rigidity of the affected muscles continues. A case of strychnia tetanus goes on rapidly increasing and lasts from a few minutes to two hours; a case of traumatic tetanus proceeds more slowly and may extend over two hours or days and even weeks.

The action of this drug not only illustrates the above principles, but the wide range of influence which it is possible for a drug to exert by virtue of its energy. In the case of nux vomica, on account of the specially selected portion of the animal body for its action, namely, the spinal cord, first, then reaching to a peripheral nerve organ, the sympathetic, the effects following its administration are far reaching.

From the most pronounced motor disturbance to affecting the most delicate special senses, such as the sense of pain, temperature, touch and pressure, also the general senses, such as hunger. thirst, fatigue, well being. Any disease energy similarly active in the same field can be successfully met by this powerful drug, as a mention of a few of its uses will indicate. Atonic dyspepsia and gastralgia; in chronic gastric, catarrh and morning vomiting of drunkards, this is next in value to arsenic. The poor appetite, the feeble digestion and the nervousness and trembling which follow the sudden withdrawal of stimulants may be removed by small doses frequently admin

istered. Atonic diarrhea, when a paretic condition of the muscular layer of the bowels may be presumed to exist. In forms of epidemic dysentary, nux vomica is indicated when there is depression of the vital processes. In anaemia, chlorosis, hemorrhagic diathesis and purpura, nux vomica is used with reference to its power to stimulate the blood making organs, which functionate under some special influence proceeding from the nervous system. A very serviceable remedy is strychnia, in idiopathic or essential epilepsy, in pale, anaemic young subjects who have petit mal, as well as grand mal, and whose attacks are nocturnal. These are but a very few of the conditions in which nux vomica, or the alkaloid strychnia are of great curative value. The reason for which is found in the fact that the selective action of the drug is on the spinal cord and sympathetic ganglia, assisting their lagging energies to again assume a normal control and improve a weak functionating system, and lessened resisting power.

All drugs used as medicines can be studied as the above, but enough has been written to illustrate the points considered.

SUMMARY.

In the study of drug therapy the following essential points are to be considered:

First. The selective power of the drug used, by which we shall know the especial portion of the organism upon which the drug acts most specifically and also, by which we shall know when disease attacks this special area, upon what weapon we can depend to reach the point of outset.

Second. The character of the energy set in operation when the drug is introduced into the system, which will be another guide for its selection; for if the phenomena are similar to the phenomena produced by the disease, the two forces can not exist in the same body. Two waves meet and there is a calm.

Third. A correct diagnosis as possible should be made, all variations in functions noted, and the pathological changes investigated, all of which give a clearer view of a field affected, and gives data for the selection of a remedy from, perhaps a number which act in this same field, with phenomena varying and with degrees of effective energy.

Fourth. The dual action of the drug should be fully understood, in order to determine the strength to be used, and by which we can recognize an aggravation caused by too large a dose, which is very difficult to determine many times on account of the similiarity of the drug and disease phenomena.

PERFORATION OF THE UTERINE WALL DURING
CURETTAGE.*

BY HUDSON D. BISHOP, M. D., CLEVELAND, O.

The operation of dilatation and curettage of the uterus is undertaken by the majority of physicians with little or no thought of possible danger. Many times, even, the uterus is explored with the curette, without anesthesia or any of the accompaniments of a major operation. In order to show that this sense of security from danger is false, I present two cases of perforation recently under my observation as follows:

Case 1. Hazel R., æt. 18. So far as was known prior to operation the past history of the case had no bearing upon the present illness This began one week before admission to the hospital with an abortion at the third month of pregnancy following the insertion of a bougie. Four days after the removal of the bougie the patient had a severe chill followed by a rise of temperature. The physician in attendance performed curettage without anesthesia during the night following the chill. There was immediate improvement in the constitutional symptoms and the lochial discharge practically ceased. On the second day, however, the temperature again rose and pelvic pain became pronounced in character. On the third day after the curettage the patient was admitted to the hospital. The constitutional symptoms were not markedly septicemic, the temperature being only 101° F. and the pulse 100, but 12 hours later the temperature rose to 104° F.

Examination showed a well developed pelvic cellulitis with the uterus in a position of marked anteversion and immovable. The tubes and ovaries were not palpable. The abdomen was distended and very tender on pressure. A diagnosis of a suppurative peritonitis following abortion was made and I decided to do the Pryor operation for pelvic infection following abortion, i. e., opening of the cul-de-sac and packing the pelvis with iodoform gauze.

Preliminary to this I attempted to explore the uterus with the curette. I at once noticed that the curette met with resistance anteriorly but posteriorly there was no resistance imparted to the instrument, except as it passed below what I supposed was the internal os. There was excessive hemorrhage throughout the manipulations. I attempted to explore the uterus with the finger but

Paper read at meeting of the Homeopathic Medical Society of Northwestern Ohio, Toledo, December, 1908.

could not do so on acount of its immobility. The situation was. cleared immediately when I again swept the curette posteriorly and saw a gush of pus come from the uterus. At this point I erred in judgment as was shown by the later findings in the case. I should have made free cul-de-sac drainage only so far as operative work was concerned. I knew that the uterus was perforated and thought, of course, that it had just occurred. I opened the abdomen in the median line in order to locate the source of the pus and repair the uterine wound. I found a double pyosalpinx with extensive adhesions. The posterior uterine wall was perforated just above the internal os, the rent being large enough to admit the finger. The lacerated tissues were gangrenous and plainly showed the freshening of their surface produced by my curette. Instead of scraping the anterior intra-uterine wall, as I supposed I was doing, I had passed through the perforation and scraped the peritoneal surface of the posterior wall. I found that I had broken into the right tube at a point where it dipped down beside the uterus. There was a suppurative peritonitis involving all of the tissues of the pelvis posterior to the broad ligament. A pan-hysterectomy was out of the question, so I opened the pus tubes and drained through the cul-desac, but with little hope of combatting the infective peritonitis with. the Fowler position and the continuous absorption saline enteroclysis.

The patient died seven hours after the operation. It was impossible to secure any definite information as to what had occurred at the time of the primary curettage. Whether or not the real condition was recognized at that time I am unable to say.

Case 2. Clara M., æt. 22. The patient had an induced abortiou at the third month of pregnancy and was curetted under anesthesia at one of the hospitals in the city. She remained in the hospital for two weeks but was not well when discharged. She had an increasing abdominal tenderness and a purulent leucorrheal discharge which would lessen and then increase. Six weeks after the abortion she was admitted to the City Hospital.

Examination showed an enlarged uterus, not freely movable, with an enlarged tube on the right side. The left tube was not palpable. The constitutional symptoms were not marked but as she was getting no better I decided on operative treatment. I explored the uterus with a dull curette and found the tissues soft and boggy. There was no placental debris. While I was speaking to the class of the danger of perforation as illustrated by the case of a few days before, I suddenly felt the uterine wall give way and saw a gush.

of blood coming from the uterus. I at once opened the abdomen and found that I had perforated the posterior uterine wall in the median line, midway between the internal os and the fundus. The perforation was small and a blod-clot had formed about it. Had there not been infection in the pelvis, I doubt if it would have produced symptoms of morbidity. It was closed with Lembert sutures. There was

a double pyosalpinx with old adhesions. Both tubes and ovaries were removed and the abdomen closed without drainage.

Convalescence was uninterrupted except that on the third day after the operation, cardiac failure was threatened on acount of an acute dilatation of the stomach which disappeared after the use of the stomach tube.

A recent writer has collected in the literature from 1895 to 1907 inclusive, 160 cases of uterine perforation occurring during the course of intrauterine instrumentation. Of the 160 cases reported, the instrument causing the perforation was the curette in 43, the dilator in 31, the catheter or uterine irrigator in 12, the sound or bougie in 17 and an unknown instrument in 57 cases. The mortality in the entire series in which the result was stated was 27 per cent. In the cases treated expectantly it was 32 per cent. It was 23 per cent in the cases treated by abdominal section, early and late, and 28 per cent in cases treated by vaginal hysterectomy. From these statistics it is quite evident that the accident is a serious one no matter what the treatment may be; but it must be borne in mind that undoubtedly many perforations occur that are not reported. If recognized they receive proper treatment and if unrecognized spontaneous recovery may take place or in case of death the cause of death is attributed to the condition for which curettage was performed.

A discussion following a paper by Jarman2 upon uterine perforation shows conclusively that the accident is by no means uncommon even among the most skillful operators. The following abstracts from this paper and discussion are of interest as bearing upon this point.

Geo. W. Jarman, Obstetric Surgeon to the New York Maternity Hospital, stated in his paper that he had perforated the uterus with a curette preliminary to an operation for double pyosalpinx.

A. Palmer Dudley, Professor of Diseases of Women, New York Post-Graduate Medical School and Hospital, said: "It has been my misfortune to perforate the uterus four times and enter the abdominal cavity.

Herman J. Boldt, Professor of Diseases of Women, New York Post-Grad