her offspring. It is society protecting itself, in parturition, not blindly, but consciously and intelligently.

Not that nature is unconscious in reproduction-least of all in parturition. But she feels only; she cannot think. She suffers and moans, but cannot speak. She rejoices too, but knows not why. Here then is the truth in its more complete form, that nature furnishes in parturition what no science or art can approach unto for a moment, or can disregard without peril. But science adds what nature is equally impotent to give-intelligence-and so preserves and perfects the work of nature.

The application of science to the actual work of obstetrics is the art of midwifery. To preserve the three elements in right and salutary relation is the perfection of obstetrics. To know when to interfere and when to abstain is the essence of practical wisdom in this field. All and every interference is not science; all possible operative procedure is not art. We need to know when nature is all sufficient, for then she surpasses any science or art. We need equally to know when the natural forces are inadequate, for then art far surpasses nature.

A lengthy familiarity with the obstetrical performances of the young and inexperienced, leads to the conclusion that with them especially, the maintenance of a judicious impartiality, in the relating of our three great obstetrical factors, is very difficult. The student's mind has been filled chiefly with visions of abnormal labor in all its phases, and crowded with the remembrances of the hundreds of acts that the physician may perform to aid in defective labor processes. And he feels that if he does not interfere perceptibly in some way, to hasten or retard, to push or to pull, to open or to close, if not do more serious things, that his professional presence is worse than useless, and his professional renown is suffering blight. Of course, the same failure to grasp intelligently the true situation, is just as liable to sit supinely waiting, when promptest action is necessary. Nothing helps us but to understand well in every particular case and at every moment the exact relation therein of the three great principles which we have endeavored to bring out by comparison and con

trast.

A genuine antisepsis, that is to say, thorough cleanliness, is all right of course. But we forget that nature when doing her work most perfectly, has no lathering and shaving, no corrosive sublimate

washing and douching, no syringing and draining, no clysters or compound cathartic pills-and finally no scepticemia. Have we not hundreds of human cases equally healthy, if we would only wait and see?

If the history of parturition holds for us one valuable indication and guide it is this, never to interfere with nature when all is well. And conversely, never to hesitate when nature shows signs of failOur art is in place only when nature falters.

ure.

THE VALUE OF THE CURETTE IN OBSTETRICS. BY HENRY EDWIN SPALDING, M.D., BOSTON.

SINCE its first introduction to the profession by Récamier, the curette has grown in favor, and its field of usefulness has become extended, until now it holds an important place in the armamentarium of every surgeon and gynecologist. The specialist in obstetrics also appreciates its value, but the general practitioner, into whose hands come, numerically considered, nearly all the obstetrical cases, too often neglects its use. This is because the gravity of the conditions calling for its use is not fully understood, its value as an instrument is not appreciated, or, the operative technique not having been learned it is looked upon with fear.

Its use is not so free from danger that it can be used carelessly, for it has been the means of serious injury when in unskilled and reckless hands. In obstetrics there is less excuse for accidents than in gynecology, for no great operative skill is required to use it successfully and safely, but a perfect knowledge of the work to be done and the exercise of judicial care are absolutely necessary.

Curetting is, perhaps, oftenest required at the hands of the gynæcologist to remove morbid conditions resulting from the imperfect evacuation of the contents of the uterus at the end of a full-term gestation, or at an abortion. If, then, the accoucheur can anticipate the gynaecologist in the use of the curette, the patient may be saved months of suffering and invalidism, and escape continually-impending danger.

A portion of retained placental tissue, although small, may set up inflammatory changes in the mucosa, and arrest the normal involution of the muscular walls. We then have the long train of symptoms incident to sub-involution and endometritis. The retained. placental tissue may, moreover, be the nucleus of polypi or other excrescent growths.

The indications demanding the use of the curette at the hands of the obstetrician are briefly these :

1. The knowledge that some portion of the placenta is retained. To discover this, the utmost care must be taken in examining the delivered mass, by spreading it upon a flat surface, the maternal side uppermost, and carefully coapting the uneven, broken, and pendulous portions. If this is done with watchful care, it is quite improbable that the retention of even a very small piece can escape detection in a normally delivered placenta.

2. An odor of putrefaction on the napkins. This is assuming that antiseptic precautions have been used to the extent of frequent bathings of the external genitalia, and gentle douching within the os vagina with sterilized water.

3. An unaccountable rise in temperature, with, perhaps, metritis, peritonitis, mastitis, phlebitis, or other indications of septic inflam

mation.

4. Frequently recurring attacks of flooding, together with delayed involution.

While some of these troubles may arise from absorption, through a lesion of the genital tract, of matter that has become septic within the vagina, they all so strongly urge the probability that something is retained within the uterine cavity as to demand a careful investigation.

Should no placental or other abnormal substance be found within the uterus, it may be that the uterine wall, at the site of placental attachment, is in an unhealthy condition, the result of inflammation in the uterine tissues. This may be suspected if the placenta has been found diseased, or from the presence of pus upon or within the placenta. Here, also, the curette will be found most serviceable in removing the offending, unhealthy tissues, thus lessening the dangers from septicæmia.

While the condition of parturition favors the easy use of the curette, strict antiseptic precautions must be observed, and the opertive technique carefully and understandingly carried out. Without careful discrimination, the softened, friable nature of the walls of the recently-evacuated uterus may be mistaken for retained placental tissue. This error has been made, and the scraping has been carried even to perforation of the uterine walls.

That curettage may be done easily and thoroughly, the use of an anæsthetic is necessary. The operator's hands and instruments must be made thoroughly aseptic; likewise, the genital tract and uterine

cavity. For this latter purpose, I prefer the free use of water that has been sterilized by boiling, followed by a light rinsing with a solution of corrosive sublimate, 1 to 2000.

Usually, in these cases, the os is so open and patulous as to make dilatation unnecessary. If, however, this is not the case, it should undergo rapid dilatation by the use of Goodell's, or some other like dilator.

The womb being brought well into the pelvic cavity, by means of manual pressure from above, or by traction from below, with tenaculum forceps deeply imbedded in the anterior lip of the cervix, the index finger of the operator is passed into the uterine cavity. well up to the fundus, and made to explore the entire walls and angles of the uterus. In this way, portions of retained placenta and all irregularities or nodosities, and disintegrating patches of the mucous surfaces, may be readily discovered and located.

Now, the finger-nail, which has been made thoroughly aseptic, can often be used most effectively as a curette. With it the offending material may be carefully detached. Thus working under the guidance of the sense of touch, there is little likelihood of removing too little or too much. Sometimes the finger-nail is palpably inadequate to accomplish the work. Then the curette must be used. Generally, it is advisable to supplement the work of the nail with the steel curette, going lightly over the surface so as to make sure of thorough removal. Here it is that skill and good judgment are needed, not only in its use but in the choice of the instrument to be used. Curettes are either dull, medium sharp, or sharp. Other varying characteristics do not demand our attention here. Probably there has been no instrument invented capable of doing more harm than the very sharp curette, which has an almost cutting edge. It would certainly be uncalled for as well as unsafe in the cases under consideration. The dull or wire curette at the other extreme is likewise ill-suited for this work. To remove firmly adherent tissue with it would require such hard pressure upon the uterine walls as might, from the bruising, provoke inflammation. The ultimate danger from this might be as great as the possible excessive use of the sharp curette, or even allowing the septic material to remain in the uterus until carried away by nature's current, the lochia, or better still, by the douche in the hands of the accoucheur.

Whatever curette is used, the degree of force required can only be