he need never expect to make such diagnosis, for this must be made purely from functional findings. While the Roentgen diagnosis may be conclusive in some instances, there are others where the confirmatory diagnosis by other means aids materially in arriving at the direct conclusion. At any rate the normal may be easily differentiated from the pathological. Checking our findings by surgical operation and post mortem examination will make our findings more accurate as time goes by. The checking up of the condition of the alimentary canal during and after treatment will give the physician and surgeon confirmative evidence of the value of this treatment. Like in other departments of medicine, our best results are obtained when the physician, surgeon and Roentgenologist work harmoniously hand in hand.

Rupture of the Uterus

*By R. R. HOLLISTER, M. D., Omaha.

Rupture of the uterus is a break in this part of the genital canal which occurs usually in connection with pregnancy or labor.

It is termed complete when the rent extends into the abdominal cavity, and incomplete when confined to either the muscular layers or to the peritoneum. Frequency. In this respect there is a great variation in the statistics. Baudl of Vienna reports nineteen cases in 40,614 labors, or one in 2,137; Jolly in Paris found 230 cases in 782,741 labors, one in 3,403; Harris in the United States, one in 4,000; Lobenstine at the New York Lying-in hospital found seventy-eight cases among 60,000 cases, one in 770; Koblanck, one in 462; Winckel, one in 666.

Etiology. As predisposing factors may be mentioned degeneration of any sort which renders the wall weaker, repeated pregnancies, especially if close together, chronic inflammations, abnormal exit, abnormal child, abnormal presentation. Trauma may be responsible, either direct external violence, but more often from the use of instruments or while doing version. All authorities agree that multiparae are much more likely to sustain this injury than primiparae. Baudl showed in 1875 that nearly all ruptures begin in the lower segment and are preceded by an abnormal thinning and distention of that portion of the uterus situated between the ring which bears his name and the

*Read before the Nebraska State Medical Association at Lincoln, May 7-9, 1912.

external os, caused by the contraction of the uterine muscle above on the child, which is not advancing. The great majority of cases are of this spontaneous nature.

Pathological Anatomy. There may be all gradations from a nicking of the cervix to a laceration the entire length of the organ. They are spoken of as transverse or longitudinal, but the pure type is seldom met with. The left side is said to suffer more frequently than the right and is usually single. The fetus may escape into the abdominal cavity, the placenta, or both together. As a rule the fetus dies if the tear is large. The uterus may relax or contract after the fetus is ejected. Blood escapes into the abdominal cavity and the intestines may come through the rent if the uterus is not contracted. The most common cause of incomplete rupture is too rapid artificial dilatation of the cervix.

Symptoms and Diagnosis. There is usually a history of a protracted labor. Pulse and temperature go up. Patient is distressed, and tender above the pubes. If no relief comes the uterus gives way, which may be felt as something tearing which gives a sense of improvement in condition, only to be followed by marked shock and hemorrhage. The fetus is no longer felt where it should be. There need not be any external bleeding and the appearance of the abdomen is not distinctive. Vaginal examination shows recession of the presenting part from the pelvic brim and usually the rent is easily felt by the examining hand, although the child may remain in the uterus. It is necessary to always think of placenta praevia, in which there is an uterus of normal shape and normal retraction ring. If the placenta is detached and prolapsed one may be lead to think of placenta praevia when none exists. If the rupture takes place slowly, with little loss of blood, the fetus in the uterus, the pains continuing and the vertex presenting, it is hard to be certain.

Prognosis. Mortality high for both mother and child. In Lobenstine's series of seventy-eight cases there were forty-six of complete rupture, twenty-nine of incomplete and three of rupture of the vaginal vault. The mortality of mother in the complete cases was 73.9 per cent;. in ruptures of vaginal vault, 33 1-3 per cent; in incomplete rupture, 27.5 per cent. A general average of 53.8 per cent. Those dying of incomplete rupture were, many of them, suffering from placenta praevia or eclampsia, which in themselves cause a high mortality. In complete rupture the fetal mortality was 83 per cent, in that of vaginal

vault 66.6 per cent, in the incomplete 52 per cent, a total fetal mortality of 67.0 per cent. The child usually dies of asphyxia, the mother at once of hemorrhage, or later from sepsis.

Coincident. Rupture of bladder or rectum or prolapse of intestines add gravity to the situation.

Treatment. The most effectual way to head off these cases is an antepartum examination at the seventh or eighth month, as is carried out at our well-equipped maternity institutions. Prolonged dry labor is dangerous. In dilatation of the cervix artificially go slowly and dispense with powerful dilators. If you are to do version try to overcome tonic contraction before you start, if it exists. If the vaginal vault is torn, packing with gauze suffices usually unless very extensive, when the uterus must be removed.

In incomplete rupture sutures and tampons usually control the hemorrhage. If not, section must be done. Never do version as it will increase the rupture.

In the complete cases if small, suture may be considered, provided the tear is small, and you can satisfy yourself that no infection has been introduced. Otherwise hysterectomy with a vaginal drain. Salt solution to restore volume of blood. Let the operation be as short as possible.

Case. Woman 23 years old who, in April, 1909, had uraemic convulsions and was delivered at the sixth month, after which she made a good recovery. Thin and fairly developed, with bilateral goiter. No tremor, tachycardia or exophthalmos. Heart and lungs normal.

She became pregnant again in July or August, 1909, and went on smoothly until February, 1910, when in the afternoon she began to have pains in lower abdomen. She was seen by her physician, who gave morphine in hopes that miscarriage might be averted. He was called again about 3 or 4 a. m., and found that delivery was necessary. This was done by version. In introducing the hand to remove the placenta, the fingers came in contact with the intestines. This happened about 6 a. m. I arrived at 11 a. m., to find the woman very much exsanguinated, pulse weak and so fast that you could count it with difficulty. Little blood flowing from the vagina.

Immediate exploration decided upon iodine disinfection; chloroform anaesthesia; median incision. Abdomen full of blood. On packing back intestines, uterus found well contracted with a complete longitudinal tear on left, slightly anterior, from

cervix almost to top of fundus. Uterine artery seen torn across in wound, oozing, not spurting.

Supracervical amputation of uterus was done without clamps as there was so little bleeding. The broad ligaments were closed by over and over sutures as far as cervix on each side, none of the arteries being tied, but care being taken to implicate them in the stitches. Cervical and abdominal drainage. Abdomen closed by few through and through silk worm gut sutures. Intravenous salt solution. In a short time pulse became fuller, and recovery was uninterrupted except for abscess of arm where salt solution was injected.

The question arises, "Would it not have been sufficient to suture the uterus?" In the light of the history of manipulation and probability of introducing infection from below, it seemed to me that hysterectomy was preferable.

Infectious Diseases of the Eye

*By J. B. POTTS, M. D., Omaha.

I wish to consider in this paper only the most common forms of conjunctivitis, and to emphasize the routine use of the microscope in the examination of all cases. It frequently will clear up a puzzling case, and save you from embarrasing positions.

For instance, the clinical pictures of pneumococcus conjunctivitis and gonorrhoea are frequently very similar, and it is a matter of no little satisfaction to both yourself and the patient to be able to hand him a prescription for a weak silver or zinc solution and say "this is not a dangerous condition-use this and in a few days you will be as well as ever." On the other hand, should you miss a proper diagnosis and say the same thing to a patient with gonorrhoeal ophthalmia, it might cost him both his eyes.

In this climate we most frequently meet pneumococcus, Morax Axenfeldt, trachoma, gonorrhoeal ophthalmia conjunctivitis, and occasionally see staphylococcus, streptococcus, micrococcus catarrhalis, influenza and Koch Weeks. Of the latter I have seen but one case, and as the culture I made did not grow the diagnosis in that case is somewhat doubtful. I wish especially to consider pneumococcus, morax and gonorrhoeal conjunctivitis.

*Read before the Nebraska State Medical Association, Lincoln, May 7-9, 1912.

Pneumococcus conjunctivitis is caused by the diplococcus of Friedlander. It is usually of sudden onset. The patient complains of a scratching sensation as though he had sand in the eyes, lachrymation and more or less photophobia. There is usually a rather thin whitish discharge, more or less in strings, the lids vary from being only slightly puffed to the eyes swollen shut. The orbital conjunctiva is hyperemic and usually shows small pin-head size hemorrhages which are quite characteristic. These may all be very much more severe. The diplococcus, as you will see later by the projectoscope, is a lance-shaped diplococcus in a capsule and is gram positive. They are found most frequently outside of the cells and the smear is characterized by a considerable amount of mucous shreds. In contrast to this the gonorrhoeal ophthalmia germs are found very frequently in the cells, and there is little or no mucus. The disease runs a rapid course, when treated lasting from five to fourteen days, and very seldom causes ulceration or other serious complications, nearly always affecting both eyes.

Gonorrhoeal ophthalmia occurs most frequently in babies, and you are all familiar with the characteristic picture of puffy lids, inflamed, congested and copious discharge of thick, creamy, yellow pus. In the adult the onset is rapid, the eye quickly becomes inflamed and painful, but the amount of discharge may not be great the first twenty-four hours. In these cases the microscope is of particular advantage as it clears up the diagnosis at once and enables us to warn the patient of his danger, protect the unaffected eye (if, as most frequently happens, only one eye is infected) and institute vigorous treatment.

The smear should be made thin and it is well to make several. Stain with mythylene blue and examine. If the field is covered with poly-morphous cells, little mucous shreds, and you find a short diplococcus located within as well as outside of the cells, the diagnosis is fairly positive. The cells frequently appear as though filled almost to bursting with the cocci, and occasionally you will find one that seemingly has just bursted and the bacteria are escaping. It is rare to find a mixed infection in the eye at this stage, which makes the diagnosis much simpler than from the vagina, etc. The whole picture is very characteristic and, to one who is familiar with it, will rarely be mistaken. However, it is well to always make a gram. There are a few cocci which, like the gonorrhoea, are gram negative, but they are rare and their clinical picture usually very different from that of gonorrhoeal ophthalmia as well as the general