number of instances. This worm has its early
life in rats and mice. From the visits of the
infected rodent to pantries and other food re-
ceptacles the food becomes infected. Such in-
fection would necessarily occur chiefly in
houses of poor construction and so among the
poorer classes. It has also been found among
inmates of institutions such as poor houses,
asylums, orphan homes, etc.
It resides in the ileum and there may be
several thousand in a single individual. Al-
though so small, it can apparently produce as
marked symptoms as the larger worms, A
diagnosis is made by finding the minute worm
or segments of it, or else by finding the eggs
under the microscope. The latter method is
the simpler for one familiar with the appear-
ance of the eggs. Male fern is probably the
only effective drug for its cure. Prevention by
keeping the food away from infected rodents
or by isolating infected patients is more de-
sirable. — {New York Medical Journal, Nov. 7,
1903.)
Haw Scarlet Fever is Transmitted. — Aaser,
after treating 3,800 cases of scarlet fever and
noting the source of infection, found that 79
were infected from patients who had been dis-
charged from the hospital, apparently free of
the disease. The patients were kept nine
weeks in the institution and carefully disin-
fected before their discharge. Desquamation
was all finished at least a week before dis-
charge. He therefore concludes that the skin
was not the source of infection in these 79
cases. He thinks they were infected from the
throats, noses or ears of those who went out.
He believes scarlet fever is contagious much
longer than is generally supposed. He says:
"The poison can apparently remain for a con-
siderable length of time in the nose, throat, or
ear. Through the secretion from these rau-
cous membranes the poison is further distrib-
uted. In this secretion, then, lies the danger
of infection.- As long as there is an abnormal
secretion the patient must remain isolated,
even if the period be twice as long as is ordi-
narily regarded as necessary, and the patient
-^ith scarlet fever should never be discharged
•t the physician has convinced himself by
'A examination of the throat and nose
that the secretion has ceased. — {Nord. Med.
Archiv., ipos, Abt. ii., Anhang 51.)
Chronic Polyarthritis and Tuberculoaisw —
Edsall and Lavenson have made a study of IS
cases of polyarthritis, partly arthritis defor-
mans and partly so-called chronic rheumatism,
with reference to the tuberculin reaction. Clas-
sification of chronic polyarthritis by different
authors is rather confusing, but by using the
distinctions formulated by Pribram they have
arrived at a pretty definite disease. On 18 of
such cases they have used the tuberculin reac-
tion. Tuberculosis, as ordinarily seen, is rather
different from the phenomena of chronic poly-
arthritis. Yet the frequent presence of pul-
monary tuberculosis, the tubercular family his-
tory and the symptoms accompanying tuber-
culosis are frequently associated with chronic
polyarthritis, and the difference between ordi-
nary joint tuberculosis and the polyarthritis is
no greater than between so-called scrofulous
glands and lymphatic tuberculosis simulating:
pseudoleukaemia. Poncet, Bar j on, Berard, and
several other French observers have noted the
possibility of such cases being tuberculosis. In
fact, Poncet is convinced of the fact that many
are tubercular. Edsall and Lavenson report
that from their experiments there is at least
weighty circumstantial evidence in its favor.
If tuberculosis should prove a factor of im-
portance in the etiology of chronic polyarth-
ritis, it will be in the group commonly called
chronic rheumatism. Yet even some of the
active cases of arthritis deformans with febrile
exacerbations may also be tubercular. Should
some of these joint inflammations prove to be
of a peculiar type of tuberculosis, it will dis-
tinctly help to clear up the confusing etiology
of these obscure lesions. — {American Journal
Medical Sciences, December, 1903.)
Splenic anaemia (Banti's Disease) — Banti
has described a condition where there is an
enlarged spleen and anaemia, associated later
with ascites and chronic interstitial hepatitis.
Dock and Warthin believe such a symptom-
complex should be called splenic anaemia. They
have made an exhaustive study of two cases
of this disease, one of which seems to have
been in the early stages with early cirrhotic
changes, and the other in a more advanced
stage with marked fibrosis of the liver. Both
of these cases had stenosis and calcification of
the portal vein. An interesting point is whether
the splenic fibrosis is primary to the stenosis
of the portal vein or secondary to it; in other
words, is the splenic enlargement a distinct
disease, or is it simply secondary to liver trou-
ble? The anaemia seems to be secondary to
the splenic trouble. They seem rather to in-
cline to the idea that splenic anaemia is a group
of pathological conditions in which even the
splenic condition is secondary; that the whole
subject needs more study to determine the re-
lationship of the different changes as they
arise. — {American Journal Medical Sciences^
January. 1904.) '
February, 1904.
PROGRESS OF MEDICAL SCIENCE.
99
SURGERY.
Under the Charge of
MAX BALUN.
The Importance of Traumatic Defects in.
the Skull. — ^The first duty of the surgeon, called
upon to treat an open compound fracture of
the skull, is to provide for an aseptic condi-
tion of the wound and to prevent pressure on
the brain by control of hemorrhage, removal
of all loose pieces of bone, elevation of de-
pressed parts, etc. If, after such removal of
loose pieces of bone, a defect in the bony skull
remains, the question arises shall we leave
this hole open or closed? This question has
been answered differently by different observ-
ers. Kocher thinks that such a hole in the
skull would act as permanent **safety-ventir'
against increase of the intracranial pressure
and prevent post-traumatic epilepsy. Horsley
believes that it does not matter whether a
small hole is left in the skull or not. Von
Bergman holds that defects in the bony skull
may give rise to epilepsy and reports four
cases in support of his theory. To decide
this important question Bunge has made
inquiries as to the condition of 13 cases of
compound fracture of the skull which were
discharged from the Koenigsberg clinic with
defects in the skull. Of these 13 cases, 10
showed disturbances due to the defect, as ver-
tigo, headache and epilepsy.. These disturb-
ances arose often several years after the de-
fect had developed. On the other hand in-
quiry concerning five cases, where the
traumatic defect had been primarily covered
by plastic operation, showed that none of these
cases had any disturbances. Secondary plas-
tic closure of a defect in three cases resulted
once in a cure of epilepsy. These statistics
indicate that every traumatic defect in the skull
should be closed primarily, that is as soon as
aseptic condition of the wound is established.
As the best method for this closure Bunge
recommends the reimplantation of the frag-
ments. These are cleansed, cut into small
pieces (the pieces of the vitrea being prefer-
able), put on the dura mater. Such a reim-
plantation IS usually successful. Otherwise
plastic closure of the defect by a slcin-peroistial
bone flap or better still by a subaponeurotic
flap including periostium and some bone is in-
dicated. Once in Bunge's cases the implanta-
tion of a boiled piece of bone taken from the
skull of a corpse was successful. The author
does not believe in hetroolastic procedures as
the imolantation of celluloid, hnrdlrubber-
celluloid, hard-rubber plates, etc. (Bunge, Mi-
ieilungen aus den Grensgebieten der Medicin und
Chirurgie, Vol. 12.)
Anomalies in the Circle of Willis. — The
blood-supply of the brain comes from the
carotid and vertebral arteries. Both of these
arterial systems communicate with each other
and with the arteries of the other side through
the arterial circle of Willis. This anastomosis
has always been considered a main factor to
provide an equal, undisturbed blood supply to
the brain. Anomalies of this circle of Willis
have been described several times, but have
been considered mainly as anatomical curios-
ities. The following case observed at the
Boston City Hospital shows that such an
anomaly in the arterial circle in case of liga-
ture of the carotid artery may be of fatal con-
sequence. A man, 35 years of age, was oper-
ated upon for a lymphosarcoma of the neck.
The tumor was adherent to the left common
carotid artery and its removal necessitated
ligature and resection of this artery. Right
after the ligature the patient showed serious
symptoms of cerebral disturbance, which con-
tinued until death occurred 24 hours after op-
eration. The autopsy showed that the liga-
ture of the carotid and a defect in the circle
of Willis had cut off the blood supply to
the left hemisphere of the brain. There was
a degeneration of the posterior communicating
arteries to impermeable threads, and an entire
absence of the anterior communicating branch-
es.. This anomaly prevented collateral circula-.
tion to the left side of the brain after ligature
of the carotid and was therefore the immediate
cause of the oedema and softening of the left
hemisphere as found in the post mortem.
(Walter C. Howe, Annals of Surgery, Dec,
1903.)
Hemorrhoids in Children are comparatively
rare, but there can be no doubt that they occur
at an early age. Allingham, Matthews, Trinska
have reported such cases. The latter collect-
ed thirty-nine of them, in children below the
age of 15; of these, five were under one year,
old. (Matthews, Diseases of the Rectum.)
Reinbach reports four new cases from the
clinic of Mikulicz; one of them, 7 weeks old,
one 35^ years, one 8 years, and one 14 years of
age. The author (Reinbach) used the specimen
of one of these cases, consisting of the whole
pile-bearing mucous membrane, which was
excised after the method of Whitehead. Sec-
tions of this specimen showed clearly that
hemorrhoids are not, as is commonly thought,
dilated veins or varicose veins, but are true an-
giomata with new formation of blood vessels
or cavernous spaces in a connective tissue ^
stroma. Reinbach holds that all hemorrhoids
should be considered tumors and should be
distinguished from the real varicose dilation of
the hemorrhoidal veins, such as are found in
pregnancy.
Most piles do not show dilated veins, but
show new formations of blood vessels or of
cavernous tissue. The practical conclusion
that Reinbach draws from this pathological
finding is, that piles should be removed by
excision, the best method being that of White-
head, and not by cauterization and ligatures,
for, if piles are true angiomata the latter meth-
ods will often be followed by relapses, as
every practitioner .has observed. {Mitteilungen
aus dem Greusgehieten der Medicin und Chirur-
gie, Vol. 12, Parts H and III.)
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lOO
PROGRESS OF MEDICAL SCIENCE.
Jour. M. S, M. S.
GYNECOLOGY AND 'OBSTETRICS.
Genital Tuberculosis. The most compre-
hensive research on the subject of tubercu-
losis of the female genital organs and peri-
toneum, which has yet been made, is con-
tained in the report of Veit, presented at the
Rome Congress last year. The translation of
Noble is now available. Veit collected a large
series of cases from various sources and after
a careful study arrived at the following con-
clusions:
Tuberculous infections are more frequent
than has been generally supposed.
It may be either primary or secondary, the
former being rare.
It may be transmitted by the blood or the
lymph stream, and is usually a descending in-
fection.
^ When primary and circumscribed, operation
is advised.
When secondary, with a tuberculous focus
elsewhere, the treatment should be general.
Locally, iodoform is the best palliative agent.
Peritoneal tuberculosis is always secondary.
It may heal spontaneously, and, when not
cured by laparotomy, there are tuberculous
foci elsewhere. (Noble, Amer. Gyn., Sept.,
1903.)
Antistreptococcus Serum. In view of the
fact that such varying reports as to the value
of antistreptococcus serum in puerperal sepsis,
are being published both in this country and
abroad, a recent investigation by Meyer is of
interest. There are four different sera: (l)
Marmorek's, produced from one variety of or-
ganism, made artificially virulent; (2) Deny's,
made from artificially virulent organisms of
several varieties; (3) Tavel's, made from un-
changed organrsms of diflferent varieties; (4)
Moser's, produced from one unchanged or-
ganism. After experimenting with all of these
the author concludes that the only eflfectual
one in protecting mice and rabbits is Marmo-
rek's. This protection seems to be due to its
power of diminishing the virulence of the bac-
teria, which are subsequently destroyed by the
cells of the body. {Zeitsch. f. klin. Med., Bd.
L., p. I45-)
Post-operative Femoral Thrombosis. Se-
cord's case of thrombosis of the left femoral
veins followed an operation for double in-
guinal hernia in a woman aged 35. Bassini's
operation was done on both sides at the same
etherization. The dissection on the right side
was the more difficult, there being conse-
quently more injury to the tissues and more
extravasation.
Under the charge of
B. R. SCHENCK.
The wounds were dressed on the 10th day.
They healed per primam, and there was no
redness about them. The convalescence was
normal, with a temperature below 100 and a
pulse below 90, until the 12th day, when
there were shooting pains in the left groin,
popliteal space, and calf of the leg. On the
14th day, the saphenous vein became palpable
and on the 15th the temperature rose to 101,
remaining there for nearly a week. The pulse
was correspondingly increased in frequency,
but did not show an acceleration previous
to the rise in temperature, as observed by
Singer in phlegmasia alba dolens. There was
some oedema in Scarpa's triangle, but none
at the ankle.
The various views as to the etiology of this
condition are discussed and 69 cases from the
literature are tabulated. Of these, 64 per
cent, followed the removal of abdominal tu-
mors. Secord calls attention to the proba-
bility that a change in the blood pressure is a
causative factor. In the author's case a truss
had been worn on the left side for two years,
and on account of the restlessness of the pa-
tient, the bandages became loose and did not
exert the accustomed pressure on the parts.
Secord's conclusions are:
(1) No single etiological factor is respon-
sible. ,
(2) The role of infection does not seem to
be an important one.
(3) Conditions of sudden decrease of pres-
sure, dependent upon the operation, probably
exert a causative influence.
(4) Treatment should be prophylactic. Trau-
matism and hemorrhage should be avoided
and sudden decrease in tension guarded
against by having the wound area well sup-
ported by well-fitting bandages.
(5) There has been no mortality in the re-
ported cases, but the occurrence of pulmonary
embolism in a certain number warns us that
this termination is not an impossible one. —
{Amer. Gyn., Oct., 1903.)
Coeliotomy in Tuberculous Peritonitis. Zesas
reports two cases of peritoneal tuberculosis,
which have remained well nine and five and a
half years respectively, after laparotomy. The
patients are both girls, 15 and 20 years of
age. After a study of 69 recent articles, the
author advocates early operation' in this dis-
ease, as he believes that spontaneous cure
rarely occurs. — {CcntralbL f. Gresg., VII. No.
II.)
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The Journal of the
Michigan State Medical Society
PUBLISHED UNDER THE DIRECTION OP THE COUNCIL
Vol. Ill
DETROIT. MICHIGAN, MARCH, 1904
No. 3
Original articles
THE LACERATED CERVIX UTERI : AMPUTATION OR
^. TRACHELORRHAPHY— WHICH ?*
H. WELLINGTON YATES,
Detroit.
The significance of a cervical tear as a
cause of uterine disease lies not in the
existence of the rent itself, but solely in
the symptoms which it produces and in
the direct influence which can be traced
to it as the prime factor in the production
or maintenance of some pathological or
functional derangement in the pelvic or-
gans or elsewhere in the body. Not all
lacerations of the uterus demand surgical
interference; if they did, every parous
woman would have to submit. Williams,
in his excellent book just published, says
"Slight tears must be regarded as an in-
evitable accompaniment of childbirth.
Many of these heal spontaneously; others,
larger perhaps, do not heal perfectly — as
a result of infection or not sufficient time
taken for convalescence, etc." The former
class will not often soliqit our attention,
but the latter usually demand it. Now,
what is the condition of a long-standing
cervical tear, and what should be our atti-
*Rcad before the Section on Gynecology and
Obstetrics at the annual meeting of the Michigan
State Medical Society at Detroit, June 11, 1903,
and approved for publication by the Committee on
Publication of the Council.
tude thereto ? Probably a simple bilateral
tear, not extensive in character, but with
the "greater part of the V-shaped injury
full of dense scar and covered by granula-
tion tissue; the cicatrix has choked off
the venous circulation in part and if the
case is a long-standing one we find not
only a swollen oedematous cervix but a
general metritis, a constriction of the
mouths of the mucous glands and small
retention cysts are the result. In the cases
that have existed a long time, these cer-
vices become hard and dense. The cicatri-
cial tissue, not the laceration per se,
is the source of trouble. Now, all of
this is, in a way, a foreign body and one
of lowered resistance. Therefore, we must
remove every vestige of it, or degenera-
tive changes may continue, and a malig-
nancy may be the. result. Granting that
the latter, of course, is the exception,
there are many other symptoms quite as
trying to the patient's comfort as those
of a more severe character. Through im-
pingement upon nerve filaments which
have a close relationship both to the cer-
ebro-spinal and sympathetic/system^iii it
I02
THE LACERATED CERVIX UTERI— YATES. Jour. M. S. M. S.
any wonder that old, long-standing, thick
plugs of scar tissue are the common ene-
mies of so many of our invalid mothers ?
Now, it is clear to me that there are
definite cases in which the old Emmet op-
eration of trachelorraphy should be our
choice, viz., those of recent injury where
little scar tissue obtains, where the whole
organ is properly involuted and, save for
the bilateral or unilateral rent, a normal
cervix presents itself. It is obviously un-
fair to this operation, however, when we
apply it to a condition of great hyper-
trophy and hyperplasia; one where the
whole or greater part of the cervix is
composed of scar tissue, which is a tissue
of lowered resistance, and one therefore
prone to degenerative change. While the
word "amputation" might perhaps better
be substituted by that of excision or trach-
eloplasty, we will, for the sake of compar-
ison to the operation of trachelorraphy,
adhere to it. Just in a word, then, let me
repeat that in the opinion of the writer,
the Emmet operation is the one of choice
only where little adventitious tissue exists
and the pathological conditions are both
recent and simple.
When the grosser lesions obtain, the
more radical measure of amputation is
called for. Emmet himself said in 1897
that "with but few exceptions amputation
is the proper means to employ for relief of
pathologic laceration of the cervix as it is
now met with." When we consider the
physiology and anatomy of the uterine
cervix, we find it made up largely of cir-
cular muscular fibers, and that one of its
chief normal functions is to dilate during
labor. Now, if an injury of any extent
takes place at parturition, and is allowed
to remain until a considerable scar tissue
forms, then the old operation of Emmet,
if done properly, demands that all this
old scar be removed, and with it it is quite
unavoidable to take some of the healthy
tissue; and since the majority of all these
injuries are longitudinal, it is obvious that
we should conserve the best interests of
the patient by removing as little of these
circular fibers as possible, for subsequent
labors demand the same and more dilata-
tion than the former ones did, and the
more we cut off these ends, the more fre-
quently will we have delayed labors, in-
strumental deliveries and subsequent tears.
The more we constrict the outlet, the more
we invite subsequent injury, and this is
truly impossible to avoid in doing the
Emmet operation where much foreign tis-
sue obtains. Dudley, of New York, calls
attention to the fact that much damage
may be, and often is, done by narrowing
the canal and obstructing the discharge
and forcing it back into the tubes, thereby
doing more harm than good. This acci-
dent is clearly overcome by amputation.
To H. P. Neuman, perhaps, belongs the
credit of giving us the best technique for
amputation. By the use of his knife and
forceps here shown, the operation is done
with neatness, accuracy and dispatch, and
the manner in which the flaps are made
and cut portions coapted in their normal
position is, to say the least, scientific and
surgical. No normal tissue need be sac-
rificed — no diseased tissue need be left.
I can best detail the technique of Neu-
manns operation by quoting more or less
directly from his article on Tracheloplasty
in the Journal of A. M. A. for April 21st,
1901, and illustrate his meaning by some
diagrams of my own here presented.
The patient being surgically prepared,
is placed in the lithotomy position and the
cervix drawn down with a vulsellum for-
ceps, bringing the uterus well into view.
The cervix is dilated and the uterus curet-
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March, 1904. THE LACERATED CERVIX UTERI— YATES.
103
Fig. II
Fio. I
ted. The vulsellum still holding the ute-
rus in a firm position, a double tenaculem
(Fig. 1) whose blades pass one another
aftd remain locked, is so placed within the
cervix that their points are directed later-
ally from within outward. By the use
of this instrument traction is made on the
inner area of the cervix, leaving the ante-
rior and posterior walls free for making
the flaps. The cervix is now transfixed
by the special knife here shown (Fig. 2)
(Barrett's modification of Neuman's) and
a clean cut made from above downward
first in the posterior lip. The anterior lip
is transfixed in a similar manner about 1
or iy2 centimeters in front of the other
and cut in the same way. The forceps is
now unlocked and removed from its hold
on the inner surface and is made to grasp
the plug of diseased tissue, as seen in Fig.
3. The partially severed portion is now
cut off with the curved scissors, cutting
PlO. Ill
Fio. IV
from left to right. Viewing the uterus
from side to side it will present much the
same look as Fig. 4. The flaps thus made
will now fall together and inward so as to
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I04
THE LACERATED CERVIX UTERI— YATES. Jour. M.S. M.S.
assume the appearance of a normal cervix.
The amputated end would appear as
Fig. 6.
canal, three in the anterior and three in
the posterior, and tied as shown in Fig.
6. The open spaces at the sides are closed
by two sutures. A single strand is left
as coming from each knot, thus facilitat-
ing in their removal. (See Fig, 7.) I
have done this operation several times
since last May, and feel that Dr. Neuman
has given us some good technique which
has come to stay.
FlO. V
The sutures of silk worm gut are now
placed in the flaps and the margin of the
FlO. VI
One of the principal things about the
operation, it seems to me, is to make a
perfect transfixion, inserting the knife
boldly through the entire cervix and thus
avoid making a thin flap. The operation
is easily done. It is quickly done, and
when done properly all adventitious tissue
is removed and the uterus is left in as
nearly normal condition as is possible.
DISCUSSION.
Reuben Peterson, Ann Arbor: These opera-
tions for lacerations of the cervix are so com-
mon in gynecological practice that perhaps we
do not g^ive them the consideration we should.