ADVERTISEMENTS—(MENTION THIS JOURNAL.) HYDROLEINE STABLE An emulsion of cod-liver oil after a modifica- Distinctively Palatable ETHICAL Hydroleine is simply pure, fresh, cod-liver oil thoroughly emulsified, and rendered exceptionally digestible and palatable. Its freedom from medicinal admixtures admits of its use in all cases in which cod-liver oil is indicated. The average adult dose is two teaspoonfuls. Sold by druggists. Sample with literature will be sent gratis on request. THE CHARLES N. CRITTENTON CO. 115 FULTON ST., NEW YORK. DIAGNOSIS OF GASTRIC AND DUODENAL ULCER.-C. Graham, Rochester, Minn. (Journal A. M. A., August 22), calls attention to four points that seem to stand out prominently in the large number of cases of gastric and duodenal ulcer. These are: First, the periodicity of the attacks. The outset is often sudden; an attack of acid dyspepsia appearing without warning or apparent cause and lasting for days or months, followed by an intermission or marked remission, lasting for days, weeks or months, and giving place again to another attack like the first. These changes are so characteristic as to often, by themselves alone, warrant a probable diagnosis. Second, the long period of time during which this cycle has continued before surgical relief is called for. Usually the history shows that the condition has run from five to twenty years, frequently longer. In a series of 258 duodenal cases, the average duration was just short 121⁄2 years. Third, the characteristics of pain, its great diagnostic significance and its place in differential diagnosis. Its distinguishing feature is not its location or the kind of pain, but its time. It varies from mild distress to very intense pain, but its appearance some time after meals (oftener it is more exact to say before meals) and its relief by eating, are characteristic. It is epigastric, radiating seldom to other areas, and in the later stages, when complications (adhesions, obstruction, perforation) have occurred, the relief by eating and other measures falls and surgery is called for. The lower down the ulcer is located, the longer, as a rule, is the relief of pain after eating, and this is one of the best indications of the location of the ulcer. Fourth Graham remarks on the usual ready control of the symptoms by the measures used to control pain during the attack-as food, alkalies, irrigation and vomiting, as being characteristic of the condition except in its later stages with complications. Purely functional hyperacidity may cause symptoms difficult to differentiate from those of early ulcer, but Graham holds that when we meet with the combination here described, we may justly look for ulcer in the stomach or duodenum in a large proportion of cases. GRAY'S GLYCERINE TONIC COMP. A well-balanced combination of glycerine, gentian, taraxacum, phosporic acid, sherry wine and carmi-natives. Every ingredient the best obtainable. Every bottle of Gray's Glycerine Tonic Comp. of uniform strength and quality. Gray's Glycerine Tonic Comp. is advertised to theme dical profession only. Each bottle contains a full pint (64 doses-2 drs. each). It is not sold in bulk. Free samples will be sent to physicians on application. Prepared only by The Purdue Frederick Co., 298 Broadway, N. Y. We call the attention of our readers to the advertisement of the Robinson- Pettet Co., Louisville, Ky., which will be found on another page of this issue. This house was established sixtyfive years ago, and enjoys a widespread reputation as manufacturers of high character. We do not hesitate to indorse their preparations as being all they claim for them. THE American Practitioner and News. “NEC TENUI PENNÂ.” "Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downwright facts at present more than anything else." -RUSKIN. VOLUME XLII. DECEMBER, 1908. Original Communications. NUMBER 12. PERFORATING WOUNDS OF UTERUS, INFLICTED DURING THE COURSE OF INTRA-UTERINE INSTRUMENTATION, BY AMIE PAUL HEINECK, M. D., Professor of Surgery Reliance Medical College; Adjunct Professor of Surgery University of Illinois; Surgeon to Cook County Hospital, CHICAGO, ILLINOIS. (A) GENERAL CONSIDERATIONS: predisposing, exciting. As to nature; as to causes; (B) An analysis of all the cases published in the American, English, French and German literature from 1895-1907 inclusive.* (C) Conclusions. GENERAL CONSIDERATIONS. PERFORATIONS of the uterus can and do occur with the most startling ease. It is difficult to determine. the frequency of this accident. Operators, as a rule, are unwilling to give publicity to such an occurrence happening in the course of their intrauterine instrumentations. There is probably no gynecologist in the world, of large experience, who has not met with this accident perhaps several times in his work. (Baldwin I.) in the reports of 3,172 consecutive autopsies held between February, 1898, and *All the literature to which I have had access. February, 1908, at the Cook County Hospital, not one case of perforated uterus is recorded. In all the cases of abortion and in all the cases of pregnancy, treated at the same institution during the years 1903-1907 inclusive (five years), 495 abortions, 2,343 pregnancies, only three perforations of the uterus occurred; two died (autopsy denied); one, treated expectantly, recovered. By diligently searching the American, English, French and German literature from the year 1895 to 1907 inclusive, I have been able to collect 160 cases of uterine perforations due to perforating wounds inflicted during the course of intrauterine instrumentation. In Hebreyend's These (Paris, 1901, Les Plaies perforantes de l'uterus) will be found some cases not included in our table. They do not in any way infirm our conclusions. So as to more intelligently discuss perforations of the uterus, it is convenient to classify them into true and false perforations. (a). True perforations may be spontaneous; that is, they may occur without the aid of violence, may be secondary or consecutive; that is, they may follow an insult to the uterine tissues, be that insult chemical, thermic, bacterial or traumatic in nature. (2 a, b). The perforation may follow the insult immediately, or only become established after an interval of time. All uterine perforations due to perforating wounds are true perforations. (b). False or pseudo uterine perforations are not perforations in fact. (3 a, b, c, d.) We will briefly discuss these pseudo perforations, and then eliminate them from this paper. They have caused diagnostic errors, followed by such operative mistakes as needless laparotomies, as unfortunate removal of intactuteri. The term pseudo perforation is used to designate a condition capable of conveying to the operator the impression that he has perforated the uterine wall, when in fact this mishap has not occurred. What, then, has occurred? 1. The uterine sound or other instrument may have slipped into a double uterus (uterus didelphys). 4, It may have entered a uterus unicornis. 2. The instrument may have slipped into the dilated uterine end of a Fallopian tube (5 a, b, c, d, e), tube (very rare) or into a bicornuate uterus. Watkins (5 b), after opening the abdomen, found that what he had diagnosed the passage of the curette into the peritoneal cavity was the passing of the curette into the Fallopian tube. In Hind's case the uterine sound was introduced in the uterus before incising the abdominal wall; after opening the abdominal cavity it was seen that the sound had threaded the whole length of the Fallopian tube. It was presenting at the abdominal orifice of the tube. In Foeckinger's case (5 a), laparotomy showed that the uterine sound was in the oviduct. In Thorn's cases (5 d), one uterus was myomatous, the other was lateroflexed and latero-verted. In the case of myoma of the uterus the uterine sound was introduced 14 c. m. Suddenly there was a lack of resistance; hasty removal of the sound followed upon this. On opening the abdomen it was seen that the sound had penetrated for a distance of 3 c. m. into the Fallopian tube. Ahlfeld (5 e), also reports a case in which, after laparotomy, it was seen that the left oviduct had been entered by a sound introduced into the uterus. Nevertheless, this occurrence, the introduction by way of the uterus, of any instrument into the Fallopian tubes, is very infrequent, so infrequent that its possibility has been denied by competent observers, be cause: 1st. Under natural conditions the lumen of the uterine end of the oviduct is so small that it is only with difficulty that one can introduce a bristle into it. 2nd. Under normal conditions the broad ligaments, and also the ovarian ligaments, maintain the Fallopian tubes in a transverse position in the pelvis. Lawson Tait was never able on the cadaver to sound the tubes through the uterus. He maintains that under normal conditions it is impossible to introduce, by way of the uterine canal, an instrument into the normal Fallopian tubes. Catheterization of the tubes is more liable to occur in the presence of such pathological conditions as uterine |