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THE CURETTE; ITS PLACE AND ITS POWER IN UTERINE THERAPEUTICS.
By GEORGE T. HARRISON, M. D., of New York County.
THE opinions of the medical profession with regard to the value of the curette have been conflicting, from the time it was first devised up to the present day. By some, extolled as of inestimable utility, by others it has been decried as an instrument excessively hazardous in its application. Thus Aran,' in speaking of the use of the curette, calls it "cette pratique hasardeuse." Becquerel says: "This means (raclement) has always seemed to me barbarous." Scanzoni' observes that "the curette recommended by Récamier and Sims for the abrasion of granulations developing in the uterine cavity is an instrument based on quite erroneous theories, and is therefore devoid of all practical utility." "We fully concur," he continues, "in the views of Hildebrandt, when he says: 'Bad defects may be evoked in the sound portions of the uterus by these sharp-edged instruments, while the diseased portions remain intact; they do not, therefore, fulfill their proper purpose, with all the harshness of their action."" The language of Dr. Emmet is equally positive in condemnation of this instrument. "As regards the instrument of Dr. Sims," he remarks, "I honestly believe that
"Leçons cliniques," etc., Paris, 1858, p. 472.
2 "Traité des maladies de l'utérus," Paris, 1859, p. 432.
3 "Krankheiten der weiblichen Sexualorgane," Wien, 1875, 5te Aufl., S. 240.
4 "Principles and Practice of Gynæcology," Philadelphia, 1880, 2d ed., p. 617.
the ingenuity of man has never devised one capable of doing more injury. . . . I have known peritonitis, cellulitis, pelvic abscess, and even death, to occur on removing these growths from the uterine canal with a curette, and in every instance the operator was dexterous in the use of the instrument. My views are based on a dearly-bought experience, and I believe that no man has a right to place the life of his patient in jeopardy by the use of either of these instruments in the treatment of this condition." Dr. Sims, on the contrary, when he so modified the original instrument of Récamier as to make it more effective and certain in application, considered that he had laid the profession under lasting obligations, and that no contribution he had made to gynaecology was so important as his reintroduction. into practice of the use of the curette. Dr. A. Martin,' of Berlin, in the concluding lines of his article upon intra-uterine treatment, gives the following testimony with regard to the value of the application of the curette: "From these observations of mine, I think that I am justified in urgently recommending the use of the curette in cases of morbid conditions of the mucous membrane of the body, whether they be connected with pregnancy or not. I consider this procedure as certain in its final result, as devoid of danger, and not more circumstantial than certainty of success and freedom from danger demand." Under these circumstances, it may not prove an altogether unprofitable study to examine the question anew in the light of modern investigation and experience.
Our problem is twofold; first, to determine what affections of the uterus demand the application of the curette, and second, to ascertain the best method of using it in an appropriate case. In 1846, Récamier devised an instrument, which he called the curette, for removing granulations from the cervical canal. The procedure he termed curettage. Four years later, he modified the construction of his instrument and extended its application
1 Dr. Emmet has reference to Récamier's curette, Sims's modification, and Simon's
"Zeitschrift für Geburt. und Gynäk.," Stuttgart, 1881, Bd. vii, Heft 1, S. 13.
to the removal of granulations, as well as of portions of the ovum left after an abortion, from the uterine cavity. Simon made use of a similar procedure in cases of malignant neoplasms of the uterus, and invented an instrument like a spoon, with which his name is generally associated.
Dr. Sims, in his work entitled "Notes on Uterine Surgery," introduced to the profession a modification of Récamier's instrument, which can be bent so as to conform to the direction of the uterine cavity. Impressed by the dangers attendant upon the use of Sims's instrument, Dr. Thomas devised a further modification, which he calls the wire-curette. This last instrument has been widely adopted in practice, and, especially in this country, it is the form of curette most generally used. My own experience is mainly with Sims's curette and with Thomas's modification. Simon's spoon I have used only in malignant growths.
In attempting now the solution of the problem first propounded, it is necessary to refer to analogous affections in other parts of the body, with the surgical procedures adopted for their relief, to give us a basis on which to rest our therapeutical principles. Says Prowchonick: "We make use of these abrading and scraping instruments, the so-called sharp spoons (essentially like curettes, and therefore often so called, and still oftener applied in place of them), for the removal of soft, spongy masses, whether in the form of tumors or purely granular, which have formed themselves pathologically on a normal, or at least almost normal, anatomical base, such as skin, muscles, fasciæ, glandular walls, and bony cavities. Surgery teaches us, also, that these particular instruments form at the same time the best guide to the recognition of the boundaries of such destructive masses, taking away in their application nothing from the normal basis-tissue, and indicating to our sense of feeling, sometimes also to the sense of hearing, although the field of operation may not be made accessible to the eye, when we have reached the normal basistissue. According to the analogy of its surgical use, the sharp spoon is indicated wherever a degeneration of the mucous mem
1 "Sammlung klinischer Vorträge," Leipzig, 1881, S. 1513.
brane has exhibited itself on a normal, or almost normal, anatomical basis, that is to say, the uterine muscle; a degeneration of a character that would lead the surgeon, in other parts of the body, to the application of the sharp spoon, such as granulations or new formations, whose transition into the normal tissue is not accurately cognizable to the eye, to the finger, or to instruments of another kind, but whose fundamental removal up to the normal basis forms the therapeutic demand of the case in hand." The researches of Düvelius,' characterized as they are by scientific exactness, have fully shown, in the first place, that, by the energetic application of the curette, sufficient material can be obtained for the purpose of microscopic diagnosis with respect to the morbid process taking place in the uterine mucous membrane; second, that, when the curette has removed the degenerated uterine mucous membrane, out of the remains left behind, a regeneration of the mucous tissue takes place, a new and healthy mucous membrane being formed by means of the young cells proliferating from the deeper parts, and that cicatrices are not produced in consequence of the use of the instrument; third, that amenorrhoea and sterility are not caused by the curette, and that, on the contrary, many women who had been formerly sterile have conceived after its application. Applying these principles to uterine affections, we may say that the use of the curette is indicated in the following morbid conditions of the uterine mucous membrane:
1. In sarcomata and carcinomata of the inner surface of the body of the uterus, when, for any reason, more radical operative procedures are contra-indicated, the use of the curette yields very satisfactory results, although they are of a palliative character. The hæmorrhage and the sanious discharges may in this way be relieved for a considerable length of time. The Simscurette in this class of cases accomplishes the object in view most effectually. In a case of round-celled sarcoma of a diffuse form, confined to the mucous membrane of the uterine body, I prolonged the life of a patient for several years by the repeated application of the Sims-curette. In carcinoma involving the
1“Zeitschrift für Geburt. und Gynäk.," Stuttgart, 1884, Bd. x, Heft 1, S. 175.
cervix, the curette has but a limited application, as other methods of treatment are here required.
2. In puerperal conditions of the endometrium evoked by retention of the remains of the ovum or of decidual membranes. When delivery has occurred at term, and symptoms during the puerperal state point to the retention of the placenta or of pieces of the membranes, it is not necessary, as a rule, to resort to the use of the curette. In such an event, the patient may be put under the influence of an anesthetic, the finger be passed into the uterine cavity, and the offending parts can be thus removed; or we may resort to the use of irrigation of the uterine cavity with hot water to which an antiseptic has been added. In some rare cases, however, these methods may fail or be inapplicable; and then the curette comes into play, and especially Thomas's wire-curette. In a case of secondary hæmorrhage occurring three weeks after delivery, I resorted to the curette, and, after removing some shreds of decidual membrane, I had the gratification of seeing the hæmorrhage cease at once and rapid involution ensue. A much wider field, however, is opened for the curette, when pregnancy is interrupted in the first three or four months. The manual removal of portions of retained ovum or decidua under such circumstances may often be accomplished, but it may nevertheless occur that this method can not be adopted. For example, the physician may be called some time after the expulsion of the ovum and then find the uterus too firmly closed to admit the passage of the finger. There may also be considerable narrowness of the vulva and vagina, and the neck may be rigid and unyielding. The hot-water intra-uterine injections may also fail to detach the firmly-adherent remnants. In these cases, the wire-curette serves a most excellent purpose. As an illustrative case, I may cite the following:
I was called, the 1st of September, 1884, to see a young married woman, whom I found suffering from a profuse uterine hæmorrhage. She informed me that an abortion had occurred in the month of June, at about the third month of pregnancy; that, at