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But if a single intrauterine douche will occasionally cause such
a penalty, how about frequent intrauterine douching repeated
every few hours as was formerly the custom with some?

If a single intrauterine douche will bring such a penalty, how
about a vigorous curettage repeated daily for several days as I
have known to be done by men who ought never to trust them-
selves with a curette in their hands? The greatest danger in the
treatment of puerperal infection to-day is injury to the uterine
wall destroying nature's barriers against the spread of infection

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192 coe: injuries to the uterus — ^nonpuerperal.

to the general system and opening new portals of entry for
infection which but for instrumental interference might per-
haps have remained localized. The intrauterine douche with
proper indications is a procedure of greatest value. The writer
would not know how to treat puerperal infection without it, but
he believes that it should be used with the greatest gentleness,
that it should not as a rule be repeated oftener than once in
twenty-four hours, and that it should be continued only so long
as the return flow shows that there is debris within the uterine
cavity needing to be washed away. A word about the curette.
It too is a most useful instrument, one which in the absence of
sufficient cervical dilatation to admit the finger is almost indis-
pensable, but much depends upon the man behind it. It may
save many patients. It has killed many.

The object sought in the treatment of puerperal infection with
septic uterine contents is cleanliness of the uterine cavity with
the least possible injury to the uterine wall in securing this result.

If you can be sure that the uterus is empty leave it alone.

If in doubt explore, but do it as gently as possible with sterile

fingers as first choice and curette as second. If septic secundines

are found within the uterus remove them as carefully as possible

with finger or curette, but do not repeat the use of the curette.

Use the intrauterine douche only so loiig as the return flow shows


lo West Fiftieth Street.


H. C. COE, M. D.,

New York.

In reviewing the somewhat extensive literature of this subject
one is struck with the fact that little if any additional light has
been thrown upon it during the past twenty years, at least as
regards pathology and etiology. The prognosis has naturally
been considerably modified since the advent of aseptic technic.
Few writers, except Heineick (whose paper and accompanying
bibliography is the most satisfactory of all that I have read),
draw a sharp line between traumatic lesions of the puerperal, or
gravid, and those of the nonpregnant uterus, such as we seek
to do in the present discussion. The Paris theses on this topic
(notably those by Richet and Mcquel) and most of the papers
based on personal cases fail to make this important distinction.

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coe: injuries to the uterus — nonpuerperal. 193

The subject is a trite one and I doubt if I can add much of
value to an audience of specialists. I recall distinctly when an
interesting discussion, introduced by the late Dr. Mund6, was
held before this Society nearly twenty-five years ago, and
similar discussions will be found in the Trans. Am. Gyn. Soc.,
while evdry text-book on diseases of women deals with the
subject to a greater or lesser degree.

I do not propose to burden you with quotations or references,
but to summarize my personal experience, as a pathologist and
surgeon, with traumatism of the nonpregnant uterus.

Anyone who has examined a fairly normal nuUiparous uterus
immediately after removal (not a postmortem specimen, or
one softened from septic infection or other causes) will find it
difficult to believe that the wall of such an organ could be per-
forated by a blunt instrument without the exercise of more
force than would be employed by a sane operator. Yet such
uteri have been perforated and by the most experienced gyne-
cologists, as many personal confessions attest. It is not strange
that under apparently normal conditions the operator to whom
this accident occurs should seek to explain it by inferring the
presence of a dilated tube, a bicornate uterus, or some change in
the resistance of the uterine wall produced by relaxation under
narcosis (the "Erschlaflfung** which was discussed a good deal
in German journals a few years ago). Since, with our present
aseptic methods (as indeed before they were introduced), per-
foration of the wall of an aseptic uterus is not usually followed
by ill results, doubtless many cases have not been recognized.
I have seen a uterus, the fundus of which was clearly the site of a
former laceration, as shown by the deep extensive cicatrix and
surrounding adhesions. But, however impossible it may
appear, it is a fact that a normal uterus may under certain con-
ditions be perforated with a blunt instrument during operation,
and that too with the use of no more than the ordinary force.

Pathology, — Certain changes in the musculature undoubtedly
favor traumatism, such as fatty or hyaline degeneration (from
endarteritis?), senile atrophy, tuberculosis and carcinoma, the
presence of a benign neoplasm (sessile fibroid), relaxation under
anesthesia (the uterus may increase in depth from i to 3 cm.),
with thinning, or diminished resistance of the wall. Lastly,
softening, or cicatrices following extension (lacerations of cervix),
malposition and fixation by adhesions.

As regards dilatation of the proximal end of the tube, admitting

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194 coe: injuries to the uterus — nonpuerperal.

a probe, sound, or curette two or three inches, thus leading the
operator to think that he had perforated the uterine wall,
while this condition is confidently described by many writers, I
am in accord with Sutton and Lawson Tait (as well as with the
former's scepticism with regard to the emptying of a pus-tube into
the uterus), that it must be an exceedingly rare condition.
Like Sutton, I have never seen such a tube at the operating or
autopsy table, and I confess that I could not demonstrate clinic-
ally the fact that I had entered a tube to the extent of several
inches. What occurs in these cases, I believe, is that the uterine
wall is actually perforated at the comu, where it is thinner
than at other points at the fundus. It is much more probable
to infer the presence of a bicomate uterus, which I have
discovered for the first time on opening the abdomen.

Spontaneous rupture, or traumatism, of the nonpregnant
uterus must be rare indeed. The injury may be located: (a)
in the portio; (6) lower uterine segment; (c) fundus.

It may be caused by: i. Blunt instruments; (a) sounds
{not probes); (6) curette; (6') douche tube; (c) dilator, single or
branched; (d) curette-forceps; (e) during morcellation of fibroids;
(/) tupelo tents. 2. Sharp instruments or scissors, foreign
bodies used for criminal or other purposes (which have a medico-
legal interest), also injuries during coitus, etc.

The traumatism may be: i. Puncture or perforation:
(a) simple; (6) attended with hemorrhage; (c) tearing of tissues,
more or less extensive; (d) injury to rectum or bladder; (e)
prolapse of intestine or omentum. Again the accident may
occur in (a) the nonseptic or (6) the septic uterus.

The following abstracts of cases in my own practice serve to
illustrate the possible injuries:

Case I. — Multipara, lacerated perineum and prolapsed
ovaries, recurrent appendicitis, uterus slightly anteflexed, depth
three inches. Introduced a dilator with too sharp a curve and
carried the handles too far backward, at the same time making
traction downward on the anterior lip. Was aware by the
penetrating of the point of the instrument that the anterior wall
had probably been perforated. Confirmed by the introduction of
a sound. No reaction or bleeding. Repaired pelvic floor, opened
abdomen and found a small perforation just above the line of
insertion of the bladder. Closed with a couple of catgut sutures.
Ventrosuspension and shortening of ovarian ligaments, appendec-
tomy. Afebrile recovery. In this instance the uterine wall
appeared to be perfectly normal and I attributed the accident to
too strong traction downward on the anterior wall, thus putting

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coe: injuries to the uterus — ^nonpuerperal. 195

it on the stretch, whUe the handle of the imperfect dilator was
carried too far backward. Fortunately the blades were not
opened, or there might have been extensive laceration, or injury
to the bladder.

Case II. — ^Perforation of cancerous uterus with a curette. In
this case I made a diagnostic curetting for suspected cancer of
the body of the uterus under ether. Sharp curette introduced
between thumb and finger brought away a small bit of brain-
like tissue. Introduced a second time, it perforated the
fundus without any sense of resistance being felt. Verified
by passage of sound. Vaginal hysterectomy performed at once
was followed by afebrile recovery. Thinning of wall only at site
of puncture where a small cancerous nodtde was found. The
patient lived three years after.

Case III. — Inoperable cancer of body of uterus. Sound intro-
duced lightly, turned forward. Immediate gush of urine;
several ounces escaping through os externum. Retention
catheter worn for two or three days, and wound healed quickly.

Cases IV to VIII. — Cervix split with ordinary Wathen's
dilator up into broad ligament, on the left side, attended with
moderate hemorrhage. Ordinary suture and no reaction. In
one case laparotomy was done (diseased tubes and ovaries), and
nothing was found but a small hematoma in left broad ligament.

Case Vlll. — (Consultation.) Deep bilateral laceration of the
cervix on the left side. Uterine artery severed and intestine
prolapsed. When I arrived I caught the artery in a clamp and
drained through the tear in lower right segment. Afebrile
recovery and patient out of bed in ten days.

I have seen other cases of injuries in hospital practice from
sharp and blunt instruments, after enucleation and morcellation
of intrauterine fibroids, etc. My experience has been confined
entirely to aseptic cases. In 1 14 cases of perforation collected
by Jakat, twenty-three terminated fatally from sepsis. He
notes that in seventy-three the injury was produced by
curettes, in nineteen by sounds, in sixteen by dilators, in six by
catheters, and in fourteen by curette-forceps. The latter is a
particularly dangerous instrument which I never use except to
remove nonadherent tissue previously detached with the

Sutton (Clin. Journal, Feb., 1908) aflSrms that whenever the
cervix is dilated beyond No. 8 (Hegar's scale) actual laceration
occurs, which may involve the entire thickness of the wall
without being recognized. Subsequent irrigation with antiseptic
fluids may cause a fatal result in a case in which the lesion would
otherwise be harmless. The same writer calls attention to the
danger of perforating the uterine wall while removing submucous

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196 coe: injuries to the uterus — ^nonpuerperal.

fibroids by morcellation — an accident with which we were unfor-
tunately too familiar in the da)rs when Thomas's spoon-saw was
a'favorite instrument for this purpose. How much easier and
safer to bisect the anterior wall, remove the neoplasm, and
suture the wound, as we do now!

Heinecke (Surgery, Gyn. and Obstetrics, vol. vii, 1908, p. 424)
analyzes 160 cases, among which he notes only four of so-called
"false perforation," in which the sound was supposed to enter a
dilated Fallopian tube. Against this theory are: i. The small
lumen of the tube; 2. The fact that the tubes are normally
transverse to the axis of the uterine canal.

De Bo vis {La Semaine Mid,, vol. xxvi, 1906) reports three
cases of supposed perforation in which no lesion was found on
opening the abdomen, which he regards as an argument against
Jarman's dictum (Trans. Am. Gyn. Soc, vol. xxx, 1905) that
the abdomen should be opened in every case. Without quoting
further from the literature, it may be assumed that as a rule
certain predisposing causes may be found in the majority of
cases of accidental injury to the nonparturient uterus in the
hands of the expert as summarized by Heinecke, viz., softening
or hyperemia of the uterus, especially at or near the menstrual
period, atrophy, senile, or due to chronic disease or former
puerperal infection; absence of the mucosa and hyperplasia of
connective tissue, hyaline or fatty degeneration and thrombosis,
tuberculosis and malignant disease.

Dilatation and curettement should not be performed indis-
criminately (vide writer's paper, "Curettement by the General
Practitioner," Med. Review of Reviews, April, 1907), always
under anesthesia, with proper instruments, and never in acute
septic or gonorrheal endometritis. The position, mobility and
consistence of the uterus should be carefully noted before hand,
and the cervix should simply be steadied by bullet-forceps, not
pulled downward. The curette is to be held lightly between the
thumb and finger, not grasped with the whole hand and forcibly
rotated, as is so often done. If a deep bilateral laceration of the
cervix is present, with resulting tissue-changes, the dilator
must be used with great care. It is not wise to introduce any
instrument into the uterus in the oflSce, but only at the operating-
table under strict aseptic precautions.

If the injury is recognized at the time, further manipulation
should be suspended, especially irrigation. Nothing is gained
in any case by washing out the nonpuerperal, aseptic uterus,

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even with sterile water. Recovery after simple perforation
in aseptic cases is the rule and no treatment is indicated except
rest and careful observation of the patient.

If the lesion is extensive, and is followed by profuse external
bleeding, or evidences of internal hemorrhage, or by prolapse
of omentum or gut, laparotomy should be performed without
delay, also in cases in which septic infection is present or

Vaginal section is contraindicated in these cases, and above
all hysterectomy, as it is impossible to determine the exact
nature of the injury through the vaginal route and the uterus
should be saved if practicable, pregnancy and normal labor
having followed repair of the lesion in several instances.

After all, as Braun von Fernwald has aptly stated; "the

dextrous operator may use any instrument; for him the art lies,

not in the instrument, but in the hand."
8 West Seventy-sixth Street.




Professor of Obstetrics and Gynecology, University of Michigan,
Ann Arbor, Michigan.

The present may be designated as the age of specialism in
medicine. The human body has been divided and subdivided
and the ills peculiar to its different parts have been carefully
studied by men whose superior knowledge derived from such
study has made them known as specialists. And the tendency
has been to more and more subdivide and limit the field of the
specialist. Time was when it was not considered derogatory
to the surgical specialist to have a family practice as well. As
much as his time permitted, he still attended to the general
ailments of the members of his old families, who were loath to
give him up for a new physician. Nowadays, and probably
rightly, the surgeon is compelled by the sentiments of the laity
and his colleagues to be a specialist in every sense of the word.
Not only that, but the general surgeon is soon forced to specialize
in his own specialty. Research work along, or peculiar success
in certain lines of work, will deluge him with patients with certain

*Read by invitation before the St. Joseph County Medical Society at South
Bend, Indiana, November 30, 1909.

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disorders until his time is largely taken up with this kind of
work. And the same thing may be said of all the present-day

Now all this specialism has had its effect upon the general
practitioner. If he be conscientious he wants his patient to
receive the best possible advice, for above all he is seeking the
cure of his patient. Yet, if he refers every patient for every
ailment to the specialist he soon will have no patients or practice.
It was well expressed by a long suffering general practitioner,
w hen he said that he found himself in the position of an umpire
or referee whose business it was to decide which specialist his
patient was to employ, his only function between such refers
being to occasionally throw in an anticonstipation pill. Yet
in the midst of all this specialism has it ever occurred to you
that there is one department of medicine quite free from special-
ism? Personally, I know of but one specialist in obstetrics;
by that meaning a man who limits his work to midwifery cases.
There are plenty of men who are specialists in obstetrics and
gjmecology, but even in the large cities there are few if any
specialists in obstetrics alone. Now when we stop to think of
this, is it not a rather anomalous condition of affairs? Why
are there no obstetric specialists when the field is such a broad
one, and when there are so many specialists along other lines?
For a number of reasons, but two in particular. Among other
reasons for specialism are the larger pecuniary returns for such
work. This does not apply to obstetrics. Except among the
wealthy, after all a small proportion of every community, it is
next to impossible to be adequately compensated for obstetric
work. If one does not believe this let him try it. To give the
necessary care to the pregnant woman, to carry her through her
labor and puerperium certainly entails as much knowledge, skill,
and labor as to remove the appendix or hypertrophied turbinates.
Yet the charge for the one is all out of proportion to what the
public willingly pay for the other. This probably is the fault
of the profession, for they have been teaching the public for many
years that child-birth is a perfectly physiologic act, and that
every woman is destined to get through her pregnancy and
confinement without mishap. Why then, naturally asks the
public, should the charges for obstetric work be anything but
low. As a consequence they resent any special charge for such
work. Hence such a field holds out but few inducements to the
specialist, if to inadequate compensation the long hours and

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night work be added. Secondly, the general practitioner has
always striven to retain his obstetric practice. He refers any-
thing from an enlarged tonsil to cancer of the stomach to the
proper specialist, but when it comes to confinement cases he
draws the line. That is his peculiar province and has been for
centuries and he proposes that it shall be his forever. When* he
is independent or worn out by long service he may give up some
of his obstetric work, but this is practically giving notice that
he is going to specialize or retire from practice, for he knows,
as his competitor knows, that the doctor who brings the baby
into the world and administers to the mother in her convalescence,
will be the family physician in the large majority of cases.
How often one hears the statement and how true it is: '*! do
not like obstetrics, I hate the night work but I have to do it,
for if I gave it up I would lose my families.*'

So for these reasons and some others, the general practitioner
is and always will be the obstetrician of the country. And being
the obstetrician is it any wonder that he desires to do the surgery
connected with his midwifery cases, in fact insists upon doing
it? Are there any reasons why he should not do it, and do it
well, if he be properly trained and studies his cases as he should?
An answer to these questions brings us to a consideration of
the relation of the general practitioner to obstetric surgery.

Now the writer has been rather vehemently criticized in
some quarters for his advice to general practitioners to sub-
stitute vaginal Cesarean section for manual dilatation where the
cervix is hard and rigid and delivery has to be accomplished
quickly. It has been claimed that such an operation demanded
special skill on the part of the operator in order to avoid injury
to the bladder or rectum, consequently such operations should
be reserved for specialists. My reply has always been, that if
this be true, vaginal Cesarean section is of very little use in
obstetrics, for the value of an obstetric operation must depend,
after all, upon whether it can be performed by the general
practitioner, for he has a hundred cases of confinement to the
specialist's one. And the practitioner has proved his ability
to successfully perform diflScult obstetric operations, specialist's
opinions to the contrary. The same objections have always
been raised to new operations in obstetrics. The application
of forceps, version, manual dilatation, symphysiotomy, abdom-
inal Cesarean section, and finally vaginal Cesarean; all of these,
at one time or the other, the practitioner has been warned against

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attempting, for fear he has not the necessary skill. Yet I notice
that the warning comes from men who hold themselves a little
above the average as regards their operative skill. However,
they forget that taken as a class there is nothing in their mental
makeup which warrants their high opinion of themselves. The
human brain is of about the same caliber when everything is
taken into consideration. Intelligence, industry and opportunity
are all that are necessary to make one proficient in any line^of
work. Why then should not the general practitioner possessing
these perform any and all the necessary obstetric operations
and do them well? There is absolutely no reason. And for
the benefit of those who shake their heads and cite the bad
obstetric surgery they have seen performed by general practi-
tioners, it may be said that just as bad surgery has been per-
formed by those who consider themselves in a different class.
Whatever may be said, the general practitioner is going to
perform his own obstetric surgery, no matter where he may
reside, no matter how easy it may be to summon the specialist.
He may not think himself competent to remove gall-stones or
do a hysterectomy, but he feels no hesitancy about the appli-
cation of high forceps, a much more intricate and complicated
operation. Somehow he feels ashamed to summon another to
perform such operations for him. A long line of physicians
before him have done the best they could with these operations,
so why should he have faint heart and be a quitter?

To my mind, the American physician is naturally a skillful
and successful surgeon. I mean that, as a rule, he is quick to see,
thinks for himself, and above all is resourceful and able to work
himself out of a tight place. More than once I have been
amazed to hear my former students relate their difficulties in
obstetric practice and learn of the success which has attended their
efforts to solve problems not infrequently presented for the
first time. I venture to state that from the operative stand-
point alone, the most brilliant obstetric surgery is to be found in
the country districts, where the doctor, alone with his patient
except for the other members of the family, administers chloro-
form and by the aid of an oil lamp performs operations which,
from the standpoint of skill, would compare very favorably
with those performed in college amphitheaters. All this shows
what can be done and will be done as long as the physician
ministers to women in their hour of need.

Yet while we sympathize with the general practitioner in his

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endeavors to retain one field of surgery for himself, it cannot
be gainsaid that there is vast room for improvement in obstetric
surgery as it is practised to-day. If we concede to the general
practitioner the right to this province, we have the same right
to demand that in a way he shall be a specialist in this depart-
ment. It is not even sufficient that he acquire and put into
practice a high degree of operative skill. Like any other surgeon

Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 21 of 109)