operation. This is a field in which the purely medical man, by study and observation, may become as proficient as the actual operator while he enjoys a better opportunity for judging impartially in the best interests of the patient. One of the greatest authorities on Cesarian section gained his reputation almost if not quite by this sort of study. There comes to us again and again the memory of one of the noblest and most promising physicians of our acquaintance whose life was sacrificed to the ignorance, on the part of his elderly attendant, of the limits of justifiable medication and of the urgent need of surgical interference in inflammation of the appendix. On the other hand, we have only recently had to crush the false hopes of a patient with advanced malignant disease whose attending physician had led her to expect a cure from operation. Many other illustrations might be given of the importance of a knowledge of the general principles of all branches of medical art, by every practitioner, however limited his own scope.

We venture to protest against the very common custom of "reading up" cases. We do not object to refreshing the memory as to crucial symptoms or making sure of a dose or acquainting oneself with the properties of some new drug. For such study, there are special reviews of the most accurate and convenient character, so that a maximum of information may be obtained with the minimum of effort. But we do believe that the man who shapes his reading according to the utterly unsystematic manner in which diseases present themselves, wastes much time in going over and over the same ground, while he loses the opportunity to broaden his experience. This is particularly true of puzzling cases or those in which the preconceived diagnosis is wrong. Let us suppose, for

example, a case in which the prominent symptom is severe pain, not exactly localized but felt in a broad area at both sides of the umbilicus. The physician may seek in vain for a satisfactory explanation from reading under the headings which his tentative diagnoses suggest. Colic, gall-stones, gastritis, cancer, ulcer, gastralgia, etc., may all prove blind leads and, months afterward, an article on locomotor ataxia may give the true interpretation of girdle pains. We suggest, therefore, that a text-book be kept on a convenient corner of the desk, and read in course, a few paragraphs or a few pages at odd moments. In the long run, such reading will give better help in particulars as well as afford a better conception of generalities, than reference to books with the direct intention of receiving light on a special

case.

In a previous issue, we emphasized the value of contemporary literature as found in periodicals of high grade and expressed the preference for books dealing with a single subject rather than those of cyclopedic scope. In regard to the latter topic, it may interest our readers to know that two members of the editorial staff of the REPORTER began the preparation of such an article, each without knowing the other's intention.

It requires time and experience to be able to judge rapidly and correctly of the value of a journal article. Too often, undue attention is paid to the author or even his place of residence. When we have to deal with some curious anomaly or an interesting case of sickness, Dr. John Smith, of Haystack Center, is as competent and deserves the same respectful attention as Prof. Bluff, of the International University, of Millionopolis,-providing always that he has a fair knowledge of medicine and can describe what he sees and thinks. In fact, we have always been inclined to

the opinion that a man who has no right to inflict his views upon the rest of the profession has still less right to impose his services on suffering humanity. Original research is always valuable, though not equally so to all who may read the report, and it usually carries its own stamp of genuineness. But medical art is too old to allow the discovery of more than a corner that has not been trodden before, and the new

is of value only as it is correlated with the old. Many articles that are only a compilation from other writings are at least convenient in affording an easy way to keep informed of the world's progress in medicine and to remind us of many forgotten details. But there is no easy nor simple way of self-improvement. Constant observation, careful attention to the work of others, close habits of study are all needful.

The operation of curetting the uterus is indicated in a number of pelvic disorders which differ widely in their nature and their gravity.

1. Probably the lesion that most frequently demands its performance is chronic Endometritis. But great care is required in the proper selection of cases; and this for two reasons:

(a.) Many cases of endometritis recover completely without any operation, but if rest, hot douches, saline aperients and the occasional swabbing out of the uterus with iodine or carbolic acid should fail, curetting is distinctly indicated, and will, in the great majority of cases, effect a cure.

(b.) Endometritis is frequently associated with other and much more serious pelvic lesions, such as pelvic cellulitis and peritonitis, with ovaritis, salpingitis, or pyosalpinx. To curette the uterus in the presence of such lesions would be to court disaster.

2. The second great class of cases which call for curetting are those where we have, as the result of the incomplete emptying of the pregnant uterus, the retention within its cavity of pieces of membrane, fragments of placenta, even portions of a putrid fetus. In these cases

* Christopher Martin, M.B. Edin., F.R.C.S. Eng., Surgeon to the Birmingham and Midland Hospital for Women, in Birmingham Medical Review.

there must be no delay in operating, but as soon as the presence of the offending fragment is diagnosed, it must be removed with the curette. In no class of cases does operative interference yield more brilliant results.

But it must be remembered that in the septic cases the prognosis depends to a large extent on the degree of septic absorption. If it be only a sapremia, the removal of the putrid fragment will cure the patient; if it be a septicemia, the outlook is much graver. Curetting will undoubtedly save many cases of puerperal septicemia where the fons et origo mali is a mass of necrosing material in the uterus, and where the systemic infection is not profound. But it is obvious that if a pyosalpinx have formed, or there be suppurative peritonitis, curetting will do positive harm. Curetting is not a panacea for puerperal fever. The best results are obtained where the symptoms clearly point to a retained and putrid fragment in the uterus, where the surgeon is called in at an early stage of the disease, and where the clinical phenomena are those of septic intoxication rather than of septic infection.

3. Curetting has been advocated as a palliative in myoma and cancer of the uterus. It has been recommended in certain cases of myoma as a means of checking the excessive losses. I cannot

too strongly condemn such a proceeding. Curetting, at best, would only temporarily relieve the patient, and might do infinite harm by inducing sloughing of the tumor and subsequent septicemia.

So, also, in the case of cancer, it is questionable if it afford any but the most transient benefit. When the growth is strictly limited to the cervix or the endometrium, we should offer the patient the more certain hope of cure afforded by vaginal extirpation of the uterus. If the disease be too far advanced for this operation, the less we interfere with it the better.

4. Lastly, curetting is occasionally demanded for diagnostic purposes. Where we suspect that the patient is suffering from early cancer or sarcoma of the uterus, we may obtain, by curetting, fragments of tissue for microscopic examination, and may thus diagnose malignant disease in its early and most remediable stage.

ur

The preparation of the patient is important. When we can choose our time, the operation is best performed about midway between two periods. In many cases, however, as when the hemorrhage is continuous or the symptoms are gent, we must operate without delay. For twenty-four hours before the operation she must rest in bed. The bowels must be freely opened the day before; and on the morning of the operation an enema should be given to ensure an empty rectum. The vagina should be well douched the evening before, and again on the morning of the operation, with some reliable antiseptic solution. Immediately before the operation, the nurse should pass the catheter and empty the patient's bladder.

The patient having been anesthetized, she must be placed in the lithotomy position-and this is most conveniently effected by Clover's crutch. Before commencing the actual operation, a final bimanual examination should be made, in order to make sure that there is no disease of the appendages and that the uterus is not fixed by perimetric adhesions.

The perineum must be pulled back by some form of speculum. I can strongly recommend the use of Auvard's speculum. This is heavily weighted with a ball of lead, so that the instrument is

self-retaining, and by its own weight pulls back the perineum and posterior vaginal wall. I have found it of great. service when I have had to perform curetting without assistance. It can only be used, however, when the patient is in the lithotomy position.

Dilatation of the cervix is not always. necessary. For instance, in puerperal cases the os is usually widely gaping and the canal patulous. There are numerous methods of effecting dilatation, each of which has its own peculiar drawbacks, though some are much more objectionable than others. Of all methods, that involving the use of tents is the most dangerous from the risk of sepsis.

It is a great advantage to be able to effect the whole process of dilatation whilst the patient is under chloroformdilating the cervix and curetting the uterus at the same sitting. For this reason I prefer the method of rapid dilatation by means of Hegar's dilators or some modification thereof. It is far less troublesome for the surgeon, it involves no suffering on the part of the patient, and I believe it to be safer than any of the methods of slow dilatation.

The anterior lip of the cervix should be seized with vulsellum forceps and drawn down to the vulva. If the uterus be so held by adhesions that it cannot be pulled down, the operation had better be abandoned. Having ascertained by means of the uterine sound the precise depth of the uterus and direction of its canal, the surgeon holds the vulsellum firmly in the left hand and with his right slowly passes the smallest-sized dilator (smeared with some antiseptic lubricant) into the uterus. If it meets with no resistance he at once withdraws it and passes the next size. If the cervix grips the dilator and resists its passage, the surgeon must press the instrument very slowly home. Having got it in he should wait a little before withdrawing it. After a longer or shorter pause the grip of the cervix will be found to relax, and then the instrument may be withdrawn and the next size inserted. If this relaxation of the cervix does not occur within a few minutes the instrument should be withdrawn and reinserted.

The limit of safe dilatation varies in

different cases. Where the patient has previously had a child it is usually easy to dilate the cervix until it will admit the forefinger. But if the uterus be nulliparous, and particularly if it be infantile, the process of dilatation is more difficult, takes a longer time to effect, and should not be carried to the same extent. As a rule it is possible to dilate a parous uterus in from ten to fifteen minutes, whilst a nulliparous womb may require half an hour or more. When the most resisting part of the cervix is at the external os it is sometimes necessary to nick it bilaterally with scissors before dilating. The chief objection to the method of rapid dilatation is that if the tissue of the cervix be very resistant it will not stretch but tear. If unnecessary violence be employed, the uterus may be perforated or even ruptured by vertical splitting. Such accidents, however, should never occur if reasonable care be taken and there be no undue force or haste on the part of the surgeon.

A less serious accident is laceration of the cervix, which may occur if its tissue be very soft and vascular, the teeth of the vulsellum tearing out when the dilator meets with resistance. If the degree of dilatation permit, the forefinger should now be passed into the uterus and its cavity explored.

For nearly all cases the sharp curette will be found preferable to the blunt one, and the best form is a modification of Simon's sharp spoon. It should be made wholly of metal so that it may be sterilized by boiling before each operation. The largest size that will easily pass the cervix should be gently introduced and passed without any force until it impinges on the fundus. Steadying the cervix with the vulsellum the sharp edge should be pressed firmly against the mucosa and the curette drawn slowly down-scraping off a vertical strip of the whole thickness of the mucous membrane and exposing the muscular coat.

By a repetition of this maneuver a series of parallel strips are removed until first the anterior, then the posterior, and then the lateral walls are

com

pletely denuded. The surgeon must then carefully curette the fundus and the two upper lateral angles leading to the Fallopian tubes.

The flushing curette is a most useful instrument when the uterus contains much debris-as in cases of retained secundines. The handle and stem are tubular, and if the instrument be connected with the tubing of a hydrostatic douch-can, will permit of the passage into the uterus during the process of curetting of a constant stream of weak antiseptic solution which carries with it, as it escapes through the cervix, all clots and loose fragments of tissue. If the solution be used hot enough it will also check bleeding.

If the flushing curette be not used, the clots and tissue debris should be wiped away by means of probes covered with absorbent wool. For the last two years I have used for this wooden skewers, instead of Playfair's probes, and have found them to answer admirably. I buy them from the poulterers in bundles of a hundred. To prepare them, the ends must be roughly rounded off with a penknife and the skewers boiled or steamed for an hour or more to sterilize them. When wanted for use, the end should be wetted and the wool rolled on in a thin film. They are so cheap that one can afford to destroy, after each operation, all the probes that have been used. probe is used twice. and in this way the risk of carrying septic infection from one uterus to another is reduced to a minimum. When it is remembered how frequently curetting is performed in septic cases, it will be seen that this risk is no imaginary one.

No

Having thoroughly washed out or wiped out the cavity of the uterus and cleared away all clots and débris, we should apply to the raw surface left some powerful cauterizing or disinfecting agent. It is better to swab out the uterus with a caustic liquid such as iodized phenol, applied on a wooden probe armed with absorbent wool. Any excess of the caustic that trickles out of the cervix must be at once removed with absorbent wool or gauze sponges.

A long narrow strip of iodoform gauze (one inch wide and one yard long) should be ready at hand, and the uterus firmly packed with it, the end being left hanging out of the cervix into the vagina. This gauze packing serves four useful purposes it soaks up all excess of iodized phenol, it checks bleeding from

the denuded surfaces, it protects the raw surface from infection from the vagina, and it insures drainage of the uterus. The vagina must be wiped free from clots, etc., and then lightly packed with iodoform gauze. A pad of antiseptic absorbent wool is placed over the vulva and fixed with a T-shaped bandage. The gauze may be removed on the third day, and thereafter the vagina douched night and morning with lysol or iodine water. In all cases the patient must stay in bed for ten days after the operation.

The immediate risk of the operation is extremely small and the ultimate re

sult excellent, if the operation be skillfully performed, in suitable cases, and due aseptic precautions be taken. Conversely, if the surgeon use unnecessary force or bungle his work, or disregard contra-indications, or neglect the rules of surgical cleanliness, the patient runs the gauntlet of such disasters and complications as rupture or perforation of the uterus, laceration of the cervix, pelvic cellulitis, pelvic peritonitis, salpingitis, pyosalpinx, septicemia, and pyemia

truly a formidable list! Not one of these evil sequela ought, however, to occur if the surgeon follow the indications I have laid down in this paper.

Dr. Dundore, (Illinois Medical Journal) writes:

Fully two decades have passed since diseases of the rectum first received recognition, and proper treatment, at the hands of the regular profession; but although, at the present time, surgeons acknowledge the importance of these cases, and their demand for active and more modern treatment, still the general practitioner, for some undeterminable reason, seems loath to give them the attention which their importance demands. That they do need more careful attention and treatment is amply shown by the intense suffering and misery which they cause to so large a proportion of humanity. It is plainly evident, to every conscientious physician, how futile it is to expect beneficial results from the treatment of any case whatever, without first thoroughly examining the patient in order to make a correct diagnosis, and yet, in dealing with a case of rectal disease, many physicians simply listen to a description of symptoms by the patient, and as a result are, in the majority of cases, entirely in the dark. as to diagnosis; the symptoms enumerated being common to fissure, fistula, hemmorrhoids and proctitis.

Again, in many instances, in which inspection of the parts is resorted to, it is quite superficial and hurried, and, the malady appearing to be a trifling one,

the physician merely prescribes some routine formula; and with what result? The disease is not cured, perhaps not even ameliorated, and dissatisfaction is experienced by both the patient and the medical attendant.

If there is one rectal disease that is slighted more than another it is fissure of the anus, and it is this subject that I wish particularly to refer to; it causes an untold amount of suffering in many cases, is often treated with little or no success, and yet there is no affection of the anus more amenable to rational treatment. In brief, the anatomy of the parts involved is as follows: The anal canal averages about an inch in length, the direction of its long axis being downward and backward; the upper boundary of the canal is formed by the white line of Hilton, above which the mucous membrane of the rectum commences, and is here thrown into vertical folds called the columns of Morgagni; the upper border of the anus is surrounded by the anal valves, which have no fixed size or number and are frequently absent.

Dr. Charles B. Ball, of Dublin, has examined a large number of rectums with reference to these valves and finds them present, so as to be easily detected, in ninety per cent. of normal rectums, varying in size from having a free margin of one fourth of an inch, to such