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the time of its occurrence, she had lost a great quantity of blood, and had since been scarcely free from a "show"; and that at times the bleeding was so free as to make her entertain grave apprehensions of a fatal result. A homœopathic physician had been in constant attendance upon her but had not succeeded in controlling the hæmorrhage; on the contrary, according to her statement, he made no effort in that direction, as he said that it was necessary for the blood to come away. The patient was pale, exsanguine, and exceedingly nervous. Examination per vaginam revealed the fact that the uterus was very much enlarged, and, consequently, was in a state of sub-involution. Assuming that the symptoms were due to retention of portions of the ovum, I made use of the wire-curette of Thomas, and extracted several pieces, one as large as the end of the thumb. I need scarcely add that the hæmorrhage was checked at once, and that involution afterward took place rapidly.

3. In the various forms of endometritis, especially those characterized by menorrhagia and metrorrhagia, in which the degenerated mucous membrane presents fungous granulations, the scope of the application of the curette is extensive. The pathological anatomy of chronic endometritis has lately been made the subject of thorough investigation by Ruge,' and a condensed statement of his researches may not be uninstructive. The mucous membrane in chronic endometritis is, according to this author, more or less strongly proliferated, vascular, soft, and spongy. The thickness is three to four millimetres, but it may attain to the thickness of a centimetre, and even exceed it. The inner surface of the mucous membrane, looking to the cavity of the uterus, is often smooth, in spite of active proliferation. In other cases, it is slightly papillary, like velvet, or elevated in the form of protuberances, proliferated to irregular rolls or even polypoid outgrowths. The uterine cavity is often completely filled with these spongy masses. Microscopically, the different forms of chronic endometritis are to be classified, according to their anatomical composition, as follows: glandular, when the

1 See Schröder's "Krankheiten der weiblichen Geschlechtsorgane," Leipzig, 1884, 6te Aufl., S. 111.



proper parenchyma of the mucous membrane, the glandular apparatus, is concerned; interstitial, when the stroma plays the chief rôle; and the mixed forms. Glandular endometritis is distinguished by a strong proliferation and multiplication of the epithelial cells. There are two varieties of this form; viz., glandular hypertrophic endometritis, and glandular hyperplastic endometritis. In interstitial endometritis, the pathological changes are to be found in the proliferated stroma, so that, in the more recent cases, proliferation of the cellular constituents is more apparent. In the older cases, the framework, or the intra-cellular substance, exhibits the pathological alteration. In the mixed forms (endometritis diffusa), the inflammatory process affects all the parts, although not uniformly. Olshausen's chronic hyperplastic endometritis (endometritis fungosa), he regards as varied in its composition. The proliferation of the mucous membrane, which can here assume the greatest dimensions, is generally diffuse, but it may be an almost purely interstitial form, so that the glands are widely separated by the strongly proliferated stroma, at the same time becoming primarily and secondarily ectatic. In other cases, the affection is a purely glandular hypertrophy, no multiplication of the glandular ducts taking place, although great enlargement of the ducts has necessarily occurred pari passu with the proliferation. There may also be a true hyperplastic glandular endometritis, with an actual multiplication of the glandular ducts. The most important symptom of chronic endometritis is hæmorrhage, typical or atypical. In some forms, dysmenorrhoea occurs.

In another class of cases, the pain is absent during menstruation, but it appears in the middle of the free interval. Other women complain of a constant pain which undergoes exacerbation during menstruation. In still another class, women are free from pain during the flow, only to have it recur when the flow has ceased. Sensibility of the uterine mucous membrane to the contact of the sound is also characteristic of endometritis. Sterility is a frequent consequence of this affection. The effect on the nervous system is shown by a train of wellknown symptoms, which it is not necessary to here enumerate.

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A priori considerations, derived from a study of the pathological anatomy, would naturally raise doubt as to the efficacy of vaginal and intra-uterine irrigation or of cauterization in effecting a restoration of the uterine mucous membrane to a healthy condition; and the experience of competent observers has fully shown how little reliance is to be placed on these methods. The indication of treatment is obviously to thoroughly remove the degenerated mucous membrane, so that this structure, forming anew, may remain normal under appropriate treatment. The curette enables us to satisfy this indication fully, especially when its use is followed by injections of iodine into the uterine cavity. Sims's curette is the form of instrument I have generally used, although, when the fungous growths were exceptionally soft, I have found that Thomas's wire-curette accomplished the purpose satisfactorily.

4. In those small, benign neoplasms of the mucous membrane of the body of the uterus, that are still confined in their growth to the uterine cavity, such as mucous and fibrinous polypi and adenoid growths. The application of Sims's curette, especially, can here effect the ablation of these small neoplasms with certainty. Dr. Emmet's curette-forceps can also be used advantageously in such cases.

5. In the secondary endometritis of areolar hyperplasia (chronic metritis), and in the endometritis complicating myoma uteri. The application of the curette in such conditions is a limited one. The procedure is especially dangerous in the case of myoma, as, in consequence of an interference with its nutrition, the myoma may suffer necrosis and undergo putrefactive decomposition, if infectious matters have been introduced into the uterine cavity. Thomas's wire-curette, however, in this latter form of endometritis, has afforded excellent results, in my hands, in a number of cases.

Finally, the curette is applicable for diagnostic purposes; and, when abnormal secretions and hæmorrhages indicate a morbid condition of the uterine mucous membrane, the curette is the most certain and the simplest means of making an exact diagnosis. Our second problem, as we have already seen, relates to

the best method of performing the operation. The principles that should guide us in its performance are those that obtain in every other surgical procedure, and they may be summed up in the following apothegms: A careful preliminary preparation of the patient; a strict observance of antiseptic precautions carried out to the minutest details; a judicious after-treatment. In the practical application of these principles, the patient should be instructed to use vaginal douches of an antiseptic solution for some time previous to the performance of the operation. The time selected should preferably be soon after menstruation. The patient must be placed upon a suitable table, and, if she be nervous and lacking in courage, an anæsthetic should be employed. Whether she should lie on her back or be put in Sims's lateral semi-prone position, will depend on the convenience of the operator. The first is to be preferred when the uterine walls are thin and flabby and it is necessary to control the movements of the curette through the abdominal walls. The anterior lip of the os uteri is seized with a tenaculum, and, unless already sufficiently open, the cervical canal should be dilated by the introduction of steel sounds (or Hegar's hard-rubber dilators) passed in succession until the proper degree of dilatation is effected. Before and after the application of the curette, the uterine cavity should be thoroughly disinfected by an intrauterine injection of an antiseptic solution. Without the expenditure of much force, the curette scrapes the anterior wall, then the posterior, and afterward the lateral angles. By giving it the proper curve, it may easily be applied in each horn where the tubes pass off, and here especially we are likely, in chronic endometritis, to find fungous growths in excess. The diseased portions of the mucous membrane manifest themselves by their peculiar softness, as a rule. After the operation, the patient should keep her bed for four or five days. As regards the question of danger in the application of this procedure, Hegar and Kaltenbach use the following language: "In a very great number of cases, we have never yet seen an injury from the use of the curette, and consider the procedure, applied in confor

1 "Die operative Gynäkologie," Stuttgart, 1881, 2te Aufl., S. 506.

mity with proper indications, as one of the most satisfactory in operative gynæcology." "This method of treatment," remarks Schroeder, "is free from danger if undertaken with painstaking observance of antiseptic precautions. Among many thousand applications of the curette and injections in simple chronic endometritis, I have, indeed, seen exacerbations of existing perimetritic inflammations ensue, but scarcely ever fresh inflammatory phenomena. One case of death from infection, to be sure, occurred before the time of antiseptics." In these views I heartily concur, my experience leading to like conclusions."

1 "Die Krankheiten der weiblichen Geschlechtsorgane," Leipzig, 1884, 6te Aufl., S. 124.

In order to avoid all misunderstanding, it may be well to state that I regard as contra-indicating the application of the curette any recent inflammatory process in the vicinity of the uterus, such as perimetritis, parametritis, oöphoritis, or salpingitis. Retroflexion of the uterus, especially if complicated with perimetric adhesions, calls for great caution in the use of the instrument.

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