Cases I and III show how difficult it is to differentiate between the hard chancre and the chancroid or soft chancre. Having examined all the primary sores that came under my charge during my service, with the object of testing this point, have found that the probable diagnosis was correct in most of the instances. The uncertainty is so great in hospital patients, where the history is of little value, and where the sores have usually been irritated by caustics, filth and continued walking, that we should always wait for secondary symptoms. If internal medication is begun before these manifest themselves, it will be imperfectly carried out, because patient and physician are both in doubt as to the nature of the malady.

In the first case, where mercury was tolerated badly, the patient improved in all respects on large doses of iodide of potassium.

Cases II, III and IV are related to show the relative value of the dorsal incision and circumcision in the treatment of concealed sores. I have tried both methods frequently; in nearly all cases treated by the first considerable cedema, and in one case sloughing followed, while after circumcision no disagreeable complications have occurred. In doing this, bichloride solution was used before and after operation, and the sore is entirely removed, if possible. All the pendulous tissue is cut off to prevent oedema.

The last case was related to illustrate the good effects of internal urethrotomy in the membranous urethra, it still being a question as to the good results of this operation as compared with external urethrotomy in these cases.

REPORT OF THE SECTION ON OBSTETRICS AND

GYNECOLOGY.

THE CURETTE AS A DIAGNOSTIC AND THERAPEUTIC AGENT IN GYNECOLOGY AND OBSTETRICS.

BY B. BERNARD BROWNE, M. D.,

Professor of Diseases of Women in the Woman's Medical College of Baltimore, etc.

The members of this Section, in deviating from the well-trodden path of making a full report of the progress in obstetrics and gynecology during the past year, do it not because sufficient material for such report is wanting, for the advances in abdominal surgery alone would be ample to occupy all the time allotted to this Section.

The Section will report as follows:

1. The Curette as a Diagnostic and Therapeutic Agent in Gynecology and Obstetrics," by the Chairman.

2. "A Temporary Clamp, for Use in Ovariotomy, Oophorectomy and Tait's Operation," by Dr. Robert T. Wilson.

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3. Puerperal Eclampsia," by Dr. G. W. Miltenberger.

4. "A Case of Labor complicated with Fibroid," by Dr. D. W. Cathell.

Believing that the curette has not yet reached the full measure of its usefulness, I offer no other excuse for making it the subject of my portion of this report.

As is well known, Recamier used his sharp curette with great success during the early part of the present century, but he did not call the attention of the profession to it until 1850. His pupil, Robert, however had announced some of Recamier's views. and results as early as 1846. Recamier found that the cauterization of the uterine cavity for the destruction of fungoid growths

and small polypi was ineffectual, and that scraping the cavity with the sharp curette gave much better results. For a time these operations were very successful in the hands of Recamier and his followers, but later on grave complications-peritonitis, phlebitis and septicemia frequently occurred-and the operation met with such decided opposition that it was altogether abandoned. Of late years, however, the dangerous, sharp curette of Recamier has been replaced by different forms of the dull curette, most of which are modifications of Thomas' dull wire curette, which was introduced about 1870. Previous to that, however, the sharp steel curette of Sims had been used to a certain extent within the cavity of the uterus, but its chief field of usefulness at present is for the removal of glandular diseases of the cervical canal, and for this purpose there is no instrument superior to it.

As a diagnostic agent in ascertaining the desired condition of the uterine cavity, in the various chronic diseases of this organ, the dull wire curette has a vast field of usefulness. Its introduction is attended by a little more difficulty than the Simpson's sound. A slight amount of dilation with a dilator is necessary in order to allow its easy passage and prevent injury to the cervical tissues; by gently passing the curette over the interior of the cavity of the uterus, a very perfect knowledge of its size and condition may be obtained. The roughness or smoothness of its surface at particular parts would indicate respectively the locality of its diseased or healthy portion; also the scraping off and removal of a small portion of the diseased structure, would give a positive knowledge of the character of the disease.

In menorrhagia, metrorrhagia, leucorrhoea and subinvolution, the symptoms which indicate the use of the curette are so pronounced that its diagnostic and therapeutic use are simultaneous. In these cases a more complete dilation, under the influence of an anææsthetic, should precede the introduction of the curette. The dilatation insures free drainage, besides, it relaxes the constriction which generally exists at the internal os, even where the external os is perfectly putulous. This constriction, which exists in nearly all cases of chronic hyperplasia of the uterus, appears to keep up a passive congestion of the organ, by interfering with the normal circulation through the vessels at the vaginal juncture. By dilatation, the circular fibres of the cervix are also relaxed, and a process of involution afterward goes on in the uterus.

Antiseptic precautions should always be observed in using the curette, and if any pain should occur, a suppository of opium or other anodyne should be used.

Contra-indications to the use of the curette, are cellulitis, pain and tenderness over the uterus, or pelvic inflammation.

The whole surface of the uterus should be gently scraped over, and all endometrial growths removed, and any roughened or uneven. surface should be smoothed off. Formerly, I always used an application of Churchill's tincture of iodine to the cavity after using the curette, but now I make no intra-uterine application, but allow drainage, and apply an absorbent antiseptic pad to the vulva. Endometrial growths* are always contined to the cavity of the uterus proper, stopping at the os internum, below which commences the region of enlarged nabothian follicles and mucus polypi in the cervix. The difference consists in the large masses of dilated glands found in the last named affection, which are absent in the former.

Polypi of the uterus are distinguished from the fact, that they are generally confined to a small part of the endometrium; while the chronic hyperplastic endometritis extends over a large surface.

In nearly all cases of chronic inflammation and hypertrophy of the nabothian follicles, or utricular glands of the cervix (of which according to Tyler Smith, there are at least 10,000 in the cervical canal alone), a thick tenacious plug of mucus hangs from the cervix which it is often difficult to remove.

In these cases, where the secretion is albuminous and persistent, and remains unchanged in spite of the use of all the stronger caustics, the Sims' curette, with sharp cutting edge, will effectually remove the hypertrophied glands down to healthy tissue, and will generally effect a permanent cure; for this purpose it is often necessary to dilate the cervix with tents before the curette is used.

In nearly all cases of supposed return of the menses occurring after the menopause and continuing for years, a pathological condition of the uterus exists, and, what has been related as a wonderful prolongation of a physiological process, is in fact a diseased condition of the endometrium, which is readily removed by the

curette.

*"On the Use of the Curette as a Therapeutic Agent in Gynecological Practice." -The Obstetric Gazette, Vol. V, page 452.

There is a class of cases we meet with, giving a previous history of abortion which may have occurred several years before; these cases present all the symptoms of chronic uterine disease, such as menorrhagia, leucorrhoea, back-ache, etc., they are generally improved by any intelligent plan of treatment; tonics benefit them for a while, and local treatment, such as vaginal douches, applications of iodine, etc., improve them very much, but they soon relapse and are as bad as before; this condition is frequently, I believe, a remote result of partial retention of the placenta. In these cases, if the dull wire curette be used, it will be found that the former placental site is studded over with numerous little cysts, from the size of a shot to that of a pea, which, when removed by the curette, will float upon water and have the appearance of small air bubbles.

In laceration of the cervix with profuse leucorrhoea, the use of the curette is attended by more benefit than intra-uterine applications, as a preparatory treatment previous to the operation for restoring the cervix.

For removing the placenta after an abortion, the finger is the most efficient curette; we may render the uterine cavity completely accessible to the exploring finger by the bi-manual method, but still better by seizing the anterior lip with the double tenaculumforceps; one of the blades grasps the vaginal aspect of the front wall of the cervix as high up as the roof of the vagina, the other at a corresponding level within the cervical canal. The uterus is capable of being pulled considerably down without any injury to its ligaments or laceration. It may be pulled down with the right hand and kept fixed with it, while one or more fingers of the left pass into the cavity and explore and evacuate it. The cavity of the uterus is thus brought within full reach of the fingers, and we can in all those cases of imperfect delivery in the early months control the emptying of the cavity from fundus to os. The manipulations necessary to secure a satisfactory result cause some suffering, though not to a great degree, which we can always save the patient by bringing her under the influence of an anesthetic.

THE FINGERS OR HAND AS A CURETTE AFTER LABOR.

We are told by many of the obstetrical works that meddlesome midwifery is a dangerous thing, that we should leave everything to nature, that any handling or manipulation about the uterus at