What are the Rational Limita- 
tions of Intra-Uterine 
Therapeutics ? 
by l 
ANDREW F. CURRIER, M. D. 
HEPRIHTBD PBOM 
SIHje Nell) ¥ovtv |ttcU(cal Jfoucnal 
for February 15, 1890. Reprinted from the New York Medical Journal 
for February 15, 1890. 
WHAT ARE THE RATIONAL LIMITATIONS 
OF INTRA-UTERINE THERAPEUTICS?* 
By ANDREW F. CURRIER, M. D. 
It seems scarcely credible that the opinions and prac- 
tice of gynaecologists should differ so widely as to the pro- 
priety and utility of invading the cavity of the uterus for 
therapeutic purposes; for it is the difference between the 
very small number who do not enter it at all and hence, vir- 
tually at least, deny the existence of diseased conditions of 
the uterine mucous membrane which are amenable to local 
treatment, and those who enter it with the same freedom 
with which they would enter any of the accessible cavities 
of the body. Now the situation and structure and functions 
of the uterus are such as to suggest the minimum of inter- 
ference, and yet experience amply proves the great advan- 
tages to be derived from interference in certain conditions. 
This is not a matter of opinion but of demonstration. The 
uterus is so divided at the os internum as to consist practi- 
cally of two distinct organs. Obstetricians have long rec- 
ognized this fact, and also the protective influence exercised 
by the cervix upon the body of the uterus in the pregnant 
state. Bennett, in his scheme of uterine pathology, consid- 
ers the cervix of such importance that he traces most vari- 
* Read before the Medical Society of the State of New York at its 
eighty-fourth annual meeting. 2 
WHAT ARE THE RATIONAL LIMITATIONS 
eties of uterine disease to disturbance in its structure. As 
Johnstone has said (Trans, of the Am. G-yn. Soc., xii, 275), 
it has a different blood supply, a different nerve supply, a 
difference in the direction and quality of its muscular fibers, 
and a radical difference in the structure of its mucous mem- 
brane ; in fact, the two parts of the uterus have entirely sep- 
arate functions. It would therefore seem rational to con- 
sider separately the therapeutics of the cervix and that of 
the body of the uterus. This involves a preliminary con- 
sideration of the pathology of each. The mucous mem- 
brane of the cervix uteri is compared bv Johnstone (loc. cit.) 
with that of the air passages, containing as it does dense 
layers of ciliated columnar epithelium which lie upon loose 
areolar tissue, and in which great numbers of mucous glands 
are imbedded. It is not without nerve filaments, for it is 
often acutely sensitive, and it is subject to frequent physio- 
logical vascular engorgements, its arteries and veins being 
thick and large and forming a kind of erectile tissue. The 
diseases to which it is subject are well known, and some of 
them have been carefully studied for many years. 
For our present purpose they may be divided into con- 
ditions which are the result of simple (i. e., non-traumatic) 
congestion, of traumatism, of infection, and of malignant de- 
generation. There is perhaps no condition which is more 
common than that which results from congestion of the cer- 
vical mucous membrane, so-called catarrhal cervical endome- 
tritis, in which the cylindrical epithelium is cast off in abun- 
dance, and the glands secrete an increased quantity of mu- 
cus. When the process is acute, leucocytes in greater or less 
abundance from the vessels are added and the secretion be- 
comes more or less purulent. This hypersecretion may be 
so excessive as to be not merely an annoyance from constant 
soiling of the person and the clothing, but even debilitat- 
ing, and not infrequently the cause of the most intense pru- OF INTRA-UTERINE THERAPEUTICS? 
3 
ritus of the skin surrounding the external genitals. These 
possibilities give an importance to the disease which forbids 
us to regard it as insignificant. The congestion in these 
cases may be attributable to obstruction to or sudden check- 
ing of the menstrual flow from a great variety of causes, to 
frequent coitus (prostitutes almost invariably suffer with the 
disease), to prolonged general anaemia, etc. The disease is 
very common in anaemic girls and in anaemic old women, 
being due in both classes of cases to local vascular derange- 
ments. Cysts of the cervical glands and polypi of the mu- 
cous membrane may be the product of congestion. So, too, 
in deformities of the vaginal portion of the cervix, in which 
it is indurated, conical, or undeveloped, the canal being nar- 
row or tortuous, congestion is often an important element in 
producing important changes of a morbid character. 
Traumatism is the source of endometritis of varying de- 
grees of intensity, especially the traumatisms which are in- 
cidental to parturition. Whatever be the form of the in- 
jury, if the cervical mucous membrane is exposed it is sub- 
jected to constant irritation, and a granulation tissue is fre- 
quently developed which shows the ordinary characteristics 
of chronic inflammation. Traumatisms in connection with 
surgical operations upon the cervix which are inefficiently or 
unskillfully performed, and which do not heal properly, fre- 
quently exaggerate a pre-existing condition of endometrial 
inflammation. The endometritis of infectious origin is of 
very common occurrence. Most common perhaps is that 
which is associated with gonorrhoea. Infection from the 
bacillus of tuberculosis may also take place, and the en- 
dometritis of puerperal fever is attributable to infection from 
the Streptococcus pyogenes. It has also been asserted that 
there may be infection from the specific germs of typhoid 
fever, diphtheria, and the eruptive fevers, though I am not 
aware of any absolutely convincing studies which have been 4 
WHAT ARE THE RATIONAL LIMITATIONS 
made in this direction. In malignant disease of the cervical 
mucous membrane extensive changes in the epithelial and 
glandular structures take place. The mucous membrane is 
first infiltrated and then breaks down, the tissue being de- 
stroyed and ulcerative conditions resulting. The areas of 
tissue contiguous to those which have already been invaded 
may undergo irritation in their epithelial and glandular ele- 
ments which may be regarded as a kind of infection pre- 
monitory of the condition which is to follow. In all these 
conditions there is little dispute as to the propriety of thera- 
peutic measures, provided one believes in the propriety of 
local therapeutic measures for uterine disease in any case. 
It may be well, however, to regard the following rational 
precautions before instituting any plan of treatment, whether 
simple or extensive : 
I. When menstruation is imminent or present, treatment 
should he withheld. An exception to this rule would ob- 
tain should the flow be very profuse or protracted. 
II. In the presence of an acute inflammatory process 
intra-uterine treatment should be withheld. For example, 
in the acute stage of gonorrhoea or with acute peritonitis 
this rule should be observed. 
III. In malignant disease of the cervix the possibility 
of severe haemorrhage attending local treatment of what- 
ever character must be anticipated and provided for. 
IV. In all cases the risk of inflammatory reaction in 
the pelvic structures remote from the cervix must be taken 
into consideration. 
With these precautions in view one may consider the 
following category of cases in the order of their severity : 
1. Those which are suitable for local applications of an 
astringent or caustic character, including electricity. 
2. Those which are suitable for the dull or sharp cu- 
rette. OF INTRA-UTERINE THERAPEUTICS? 
5 
3. Those which are suitable for plastic operations. 
4. Those which are suitable for extensive removal of 
tissue. 
The first class of cases will include the catarrhs which 
are without serious symptoms. Tn many of them there is 
no need of local treatment other than the systematic use 
of vaginal douches, and it must not be overlooked in any 
of them that there may be a constitutional cause which is 
the original source of the local trouble. It may be added 
by way of parenthesis that vaginal douches should consti- 
tute a feature of the toilet of every woman, though, of 
course, specific directions are appropriate for each case. If 
the glandular secretion is very profuse, various solutions 
may be of use to coagulate it and to stimulate the glands 
to more healthy action. A powerful solution is preferable, 
and I do not remember to have ever seen harm result when 
the application was limited to the diseased cervical mucous 
membrane. Solutions of persulphate of iron, nitrate of sil- 
ver, iodine, carbolic acid, antipyrine, and even nitric acid, 
chromic acid, and chloride of zinc, may all be used with ad- 
vantage in quite a concentrated form. Such applications 
repeated every two days will soon correct the diseased con- 
ditions, though they may not produce a radical cure. The 
same end may be obtained by a few applications of a gal- 
vanic current of low tensipn, the positive electrode being 
introduced within the cervical canal. In the exaggerated 
conditions of chronic endometritis great satisfaction may 
be derived from the use of the curette—the dull curette for 
the less severe and the sharp one for the more severe cases. 
It is surprising to see how great a quantity of retained se- 
cretions can sometimes be scraped out of the cervical canal, 
and also the promptness with which contraction of the tis- 
sues and a normal condition of secretion supervenes. For 
infectious endometritis, more particularly the gonorrhoeal 6 
WHAT ARE THE RATIONAL LIMITATIONS 
variety, the indication is, of course, to use a germicide, and 
in the treatment of a great many cases I have never found 
anything which would equal the nitrate of silver. I use it 
habitually with the utmost satisfaction in a watery solution 
containing sixty grains to the ounce. 
If the cervical mucous membrane is extensively exposed 
—in other words, if ectropion exists—the application of 
astringents or caustics, or even the use of the curette, is but 
palliative; it is better to excise the entire mucous mem- 
brane after Schroder’s method, or do a modified amputa- 
tion of the cervix according to Hegar’s method, or perform 
Emmet’s operation of trachelorrhaphy. 
In the cases of malignant disease of the cervical mu- 
cous membrane it often happens that extensive scraping 
with the sharp curette is all that can be done, on account 
of the extent and severity of the disease. If the disease is 
still in an early stage, a radical operation should be per- 
formed, and it is logical to believe that with a morbid con- 
dition which develops as does cancer, the more tissue re- 
moved the greater the probability of passing beyond its 
utmost limits—that is, extirpation of the entire organ would 
seem to be a rational procedure in all cases in which it is 
feasible. It must be admitted that the ultimate results of 
this operation have not been as favorable as was hoped. 
Cysts and polypi should be removed in accordance with 
customary rules of surgical procedure in such cases, and 
this applies alike to polypi developed from mucous mem- 
brane and those which are composed of fibrous tissue. 
The utility of dilatation may be considered beyond the 
limits of discussion, but it is very questionable whether the 
free use of the powerful and dangerous instruments which 
are now so much in vogue indicates a health)' medical opin- 
ion. Without stopping to mention in detail the dangers 
attending the use of such instruments in inexperienced OF INTRA-UTERINE THERAPEUTICS? 
7 
hands, I would advise those who are general practitioners 
neither to use nor to possess them until they have thor- 
oughly familiarized themselves with the resisting power of 
the uterine muscle by the use of the graduated uterine 
bougies. I can not recall a case in which it has not been 
possible to obtain all the dilatation which is requisite by 
the use of these less dangerous instruments. 
The os internum forms a natural barrier to the cavity 
of the body of the womb. It is the innermost portal of 
the sanctuary, for what portion of this human “temple” 
can be more sacred than that in which are developed the 
beginnings of life? It is the limit beyond which, in many 
cases, neither germs vital nor morbid ever pass. It has a 
sphincteric action, which is manifest enough at times when 
one endeavors to penetrate it with a probe or sound, the 
sphincter being formed by the Z-shaped fibers of Sappey, 
which are longitudinal in the cervix and transverse at the 
os externum and the os internum. It has also several fas- 
ciculi of longitudinal fibers in the anterior and posterior 
walls of the cervix, which have been described by Desor- 
meaux and Jacquemier (see Nouv. arch d’obst. et de gyn., 
May, 1889, p. 214). This knowledge of the structural 
anatomy is important, because it explains the resistance 
which is often encountered when the uterus is sounded. Its 
extreme sensitiveness in nulliparous women, and the exten- 
sive radiation of pain which may follow its irritation, are 
matters of frequent observation, and this suggests the ob- 
servation that the use of a fine, flexible probe for sounding 
the uterus is quite as efficient in most cases, and far less 
likely to provoke pain and other undesirable conditions, 
than the use of sounding instruments of larger caliber. It 
may also be pertinent to emphasize the necessity of intro- 
ducing only aseptic—that is, clean—instruments into the 
uterus, for it is the use of dirty instruments which is largely 8 
WHAT ARE THE RATIONAL LIMITATIONS 
responsible for the prejudice which exists against intra- 
uterine therapeutics in general. Instruments which are sur- 
gically clean will rarely cause or increase disease. The 
therapeutics of the mucous membrane of the body of the 
uterus involves entirely different considerations from those 
which concern the neck. Here we are approaching the 
danger line. The subject is one on which the best minds 
have differed radically. The question of diagnosis is often 
a very difficult one to settle, and the great importance of 
the matter is ample excuse for a repetition of what may be 
familiar and well worn to all my hearers. The mucous 
membrane of the body of the uterus, both in its physio- 
logical and pathological states, has been the subject of the 
most careful investigations by some of the most competent 
contributors to medical science. One has but to mention 
the names of Leopold, Ruge, Williams, Kundrat and Engel- 
mann, Moricke, and Wyder to substantiate this assertion. 
It is from this membrane that the decidua of pregnancy is 
developed, and with each recurring menstruation it is ex- 
foliated to a greater or less extent, to be immediately re- 
newed for a subsequent menstruation, or the development of 
a decidua for a fecundated ovum. Without attempting to 
harmonize the points of histological controversy in the mat- 
ter (for an exhaustive analysis of which, see series of papers 
by Dr. Mary Putnam Jacobi on Studies in Endometritis, Am. 
Jour, of Obst., 1885), we may accept as a working definition 
that it is composed of a network of areolar tissue, in which 
is imbedded ciliated columnar epithelium. It also contains 
simple and branched tubular mucous glands in great num- 
ber, the lining epithelial cells of which are continuous with 
the epithelium at the surface of the membrane. There are 
also in the structure lymphatic spaces with endothelial lin- 
ing (Leopold), or, according to another observer (Schmitt), 
lymphoid corpuscles, or, according to another (Meyer), OF INTRA-UTERINE THERAPEUTICS? 
9 
lymphoid corpuscles resembling endothelia. The mucous 
membrane is attached to the underlying muscular parenchy- 
ma by bundles of connective tissue which carry its nutrient 
blood-vessels. With a lining epithelium which is easily 
eroded, delicate blood-vessels which are easily ruptured, and 
a thousand open mouths of lymphatics which lead directly 
to the peritonaeum, it may be readily understood why this 
wonderful tissue is so subject to disease, and the medium 
by which disease is transmitted to other parts. All the ele- 
ments of this tissue—epithelium, glands, connective tissue, 
blood-vessels, and lymphatics—may be involved in disease 
processes, and, according to certain French and German 
observers, extensive disease seldom if ever attacks it with- 
out also involving the underlying muscular parenchyma 
(see Lumpe, Wiener klin. Woch., 1888, i, 696; Siredey, 
Diet, de med. et de chir. prat., p. 631, article Metrite ; 
Doleris, Nouv. arch, d’obst. et de gyn., 1887, p. 100; 
hand-books of De Sinety and Courtv). It may occur in 
children as well as in adults, especially in connection with 
the eruptive fevers (Siredey, loc. cit.). It is common alike 
in puerperal and non-puerperal women, and may be due, as 
in disease of the cervical mucous membrane, to congestion 
(non-traumatic), to traumatism, to infection, or to malignant 
disease. It is far less common than cervical disease, though 
there is great difference of opinion in respect to its fre- 
quency. 
Thomas (op. cit., chapter on Chronic Corporeal Endo- 
metritis) sustains the assertion which I have made, and 
quotes Bennett, Byford, and Tilt as also sustaining, West 
and Aran as opposing it. Its chief symptoms are pain, 
haemorrhage, and glandular discharges; but these are not 
invariably present, and other symptoms—such as general 
debility, sterility, and reflexes of varying character—have a 
more or less intimate relationship with it in many instances. 10 
WHAT ARE THE RATIONAL LIMITATIONS 
The use of the term chronic endometritis for this condition 
(excluding the neoplasms), when it is of long duration, is 
rather a matter of convenience than of accurate nomencla- 
ture, for in many of the cases an inflammatory process does 
not exist. I am convinced that many errors of diagnosis 
are made by depending too much upon the discharges which 
proceed from the uterus. It is comparatively an easy mat- 
ter to exclude discharges of cervical origin, but very diffi- 
cult to exclude those which proceed from the tubes in mak- 
ing a diagnosis from this symptom. In view of the great 
frequency of suppurative salpingitis, it is not improbable 
that many cases of that disease have been hastily diagnos- 
ticated as endometritis. A similar error may be made with 
reference to haemorrhage from or sensitiveness of the uterus. 
The former may be due to tubal disease, or to malignant 
disease apart from the uterus (e. <7., in malignant disease of 
the omentum or mesentery) ; the latter may proceed en- 
tirely from peritonitis. It is important to know whether 
the disease is primary or secondary. In the latter case 
intra-uterine treatment is frequently contra-indicated. Gen- 
eral debility, anaemia, and the continued and eruptive fevers 
may be accompanied with symptoms of endometritis which 
do not demand local treatment, especially in the young and 
unmarried. Until civilized society is constituted differently 
from its present arrangement, we are bound to pay a certain 
amount of deference to prejudices in this direction. 
Non-traumatic congestion is responsible for many of the 
cases of so-called chronic endometritis, and this may pro- 
ceed from many sources. Uterine displacements interfer- 
ing with the venous circulation, atresia of the canal, con- 
genital or acquired, the influence of remnants of retained 
placenta or decidua, fibroid tumors contiguous to the endo- 
metrium—these and many other causes may result in con- 
gestion leading to hypertrophy or hyperplasia of the OF INTRA-UTERINE THERAPEUTICS? 
11 
mucous membrane, to polypoid, or papillary, or villous ex- 
crescences, retention or excess of glandular secretions, with 
more or fewer of the symptoms to which allusion has already 
been made. 
Traumatism is a less common cause of endometrial dis- 
ease. It has been a question with some of the advanced 
advocates of the influences of infection whether traumatism 
alone ever produces inflammation. In my own mind, there 
is no doubt that it may. Aside from the question of un- 
clean hands and instruments, we know there are many indi- 
viduals with whom the health poise is in such a condition 
of unstable equilibrium, often from excessive sensitiveness 
of the nervous system, that any unusual irritation of the 
uterine mucous membrane will cause most violent reaction. 
The traumatisms of parturition, of surgical operations 
upon the uterus, and the occasional effect of powerful caus- 
tics to the endometrium may be mentioned among the pos- 
sible causes of disease of this structure. 
Infection is a most prolific cause of the condition under 
consideration, and the peculiar construction of the mucous 
membrane which has been referred to renders it a very at- 
tractive field for infectious agents. Perhaps first in im- 
portance are infections which occur during the puerperal 
period, especially in cases in which the foetus is cast forth 
prior to maturity. In such cases, unless intelligent anti- 
septic treatment is resorted to, the consequences may be 
very severe. How many cases of endometritis, either un- 
complicated or combined with disease of the annexa, are 
traceable to want of proper care after an abortion or a labor 
at term ! The infection of gonorrhoea and syphilis, espe- 
cially the former, may result in very decided inflammatory 
lesions of the endometrium, and the profession at large is 
only beginning to realize the significance of this disease in 
the pain, the sterility, the peritonitis, and. the prolonged 12 
WHAT ARE THE RATIONAL LIMITATIONS 
endometritis which it so often causes. Other infectious dis- 
eases—tuberculosis, diphtheria, and the eruptive and con- 
tinued fevers—have been demonstrated to be causes of en- 
dometritis.- It is evident that in all such cases the cervical 
mucous membrane is first attacked, the process then extend- 
ing to that of the body. It must be admitted that it is 
often difficult to trace a disease of the endometrium to any 
one of the three aetiological elements—congestion, trauma- 
tism, and infection—as they are often combined. They may 
also be implicated to a greater or less extent when malig- 
nant disease is present, but the presence of this disease can 
usually be ascertained by the aid of the microscope, when 
clinical signs are wanting in positiveness. I say usually, 
for there are transition periods from the benign to the 
malignant, when an exact diagnosis is impossible, and a cor- 
rect diagnosis may be equally impossible from the portion 
of tissue which is obtained for examination. Malignant 
disease of the endometrium may take the form of sarcoma, 
carcinoma, or adenoma, and it is far less common than 
malignant disease of the cervix. 
A great deal of ingenuity has been displayed in classify- 
ing and subdividing the various forms of endometritis with 
reference either to clinical or anatomical peculiarities. I can 
not see that such a multiplicity of distinctions serves any 
useful purpose, certainly when therapeutic procedures are 
under consideration. Thus we have e. dysmenorrhoica 
(Schroder, see Ilandbuch der K. der weib. Gescb., 6. Aufl., 
p. 110); e. chronica hyperplastica (Recamier, Nelaton, 
Olshausen, Arch. f. Gyn., viii, 97 ; Heinricius, Arch. f. 
Gyn., xxviii, 161), which is the most fitting and appropriate 
of all these terms; e. haemorrhagica (Schroder), in which 
haemorrhage is the conspicuous symptom ; e. decidua 
(Schroder) in cases in which there is inflammation of the 
endometrium during pregnancy, and which usually termi- OF INTRA-UTERINE THERAPEUTICS? 
13 
nates in abortion ; e. polyposa, e. villosa, and e. fungosa, 
which are sufficiently indicated by the term chronic hyper- 
plastic endometritis. 
Ruge (Zeitsch. f. G. u. G., v, 317) differentiates upon an 
anatomical basis e. interstitialis, e. glandulosa, and e. 
mixta, and Schott (Volkmann’s Sammlung, No. 161) de- 
scribes e. menstrualis and e. menorrhagica. The rare forms 
e. atrophica and e. desiccans, in which there is extensive 
exfoliation of the endometrium, even including muscular 
tissue, are also described. 
The question of treatment, to which all the foregoing is 
subsidiary, is one which abounds in contradictions quite 
as much as do the questions of anatomy and diagnosis. At 
the meeting of the American Gynaecological Society in 1879 
papers upon this subject were read by Dr. White, Dr. Bat- 
tey, and Dr. Jenks, and discussed by Dr. Sims, Dr. Thomas, 
Dr. Bozeman, Dr. Goodell, Dr. Munde, Dr. Reamy, Dr. 
Howard, and others. The first three expressed conserva- 
tive views as to the propriety of intra-uterine applications 
for endometritis, though Sims and Thomas were advocates 
of the curette. The others advocated great freedom in 
intra-uterine treatment. Emmet’s strong objections to any 
form of intra-uterine therapeutics, with the exception of the 
very infrequent use of the dull curette, are well known. 
Among French gynaecologists all forms of intra-uterine 
treatment are in vogue, more particularly the use of the 
curette, under the influence of the teachings of Doleris. In 
Germany the tendency is also toward great freedom in in- 
tra-uterine treatment, Lumpe being almost alone (Wiener 
klin. Woch., 1888, i, 696) in taking a stand which is 
only slightly less positive than that of Emmet. In almost 
all the other countries of Europe the curette is in favor, 
with more or less adherence to the use of powders, pastes, 
solutions, and irrigations. Heinricius (loc. cit.) has made a 14 
WHAT ARE THE RATIONAL LIMITATIONS 
very complete and detailed statement as to the advocates of 
the different methods of intra-uterine treatment which will 
be found very interesting and instructive. The literature 
of the subject is large, and one can find almost any phase 
of opinion which is desired. My own opinions in this 
matter are as follows : 
I should divide the subject of intra-uterine therapeutics 
into three parts, the first of which will include treatment by 
irrigation, the second treatment by the use of solutions, 
pastes, or powders, and the third treatment by the curette. 
In any case it is desirable that the uterine cavity be suffi- 
ciently dilated to secure free exit of all fluids, hence arti- 
ficial dilatation will frequently be of service. The use of 
tupelo or laminaria tents with proper precautions is often 
desirable. I have never seen any harm from their use. The 
use of stem pessaries is objectionable in most cases. I have 
seen much harm result from the irritation which they cause, 
and have discarded them entirely. If there is great dis- 
placement of the uterus, drainage will, of necessity, be im- 
perfect. Capillary drainage may be effected by the occa- 
sional use of a thin tent of iodoform or bichloride gauze, 
which should not be retained longer than two days. In 
puerperal cases irrigation with hot antiseptic solutions will 
frequently be of the greatest value, with or without the use 
of the curette. Since this method was revived by Winckel 
and von Griinewald it has been extensively adopted. The 
possible dangers are more than counterbalanced by the ad- 
vantages to be gained. Either the Chamberlain glass tube 
or the Bozeman-Fritsch double catheter will be found very 
serviceable in performing this operation. In non-puerperal 
cases irrigation alone is seldom indicated. If curetting has 
been performed, the detritus may be removed by irrigation, 
care being taken in all cases that there is a free outflow of 
all the fluid introduced. Continuous or frequent irrigations, OF INTRA-UTERINE THERAPEUTICS? 
15 
which have been zealously advocated in certain quarters, in- 
volve much disturbance of the patient, are usually unneces- 
sary, and are not without considerable danger. Intra-uter- 
ine treatment by means of pastes, powders, and solutions is 
not of general utility. In puerperal cases in which there is 
a suspicion of sepsis a pencil of iodoform in the uterine 
cavity is highly approved by some excellent authorities. 
Applications of powerful astringent and antiseptic solutions 
may also be made upon the mucous membrane in such cases 
with considerable advantage, especially after the membrane 
has been curetted. In non-puerperal cases haemorrhage may 
be checked by the application of astringent solutions and 
powders, and pain may be relieved. Pastes and unguents 
are often useless, as they may not be dissolved, are often 
inert, and may even be highly irritating by their long-con- 
tinued presence in the cavity. Of course there are cases in 
which they are beneficial, but in general this is not a use- 
ful method of medication. In hyperplastic endometritis, for 
which the method of treatment under consideration is most 
frequently employed, it must be remembered that though 
benefit may be derived by it, such benefit is only palliative 
in the great majority of cases, the source of the trouble re- 
maining. 
This brings us finally to the subject of treatment with 
the curette, which is more radical and more frequently cura- 
tive than any other method. The curette is primarily an 
instrument for diagnosis; it is a prolonged finger, and as it 
is gently passed over the mucous membrane it informs us 
with accuracy whether any condition exists which requires 
active interference. In puerperal cases it is invaluable for 
the removal of bits of placenta or shreds of decidua which 
might result in great mischief. A softened and thickened 
endometrium which may have been the cause of an abortion 
can be scraped and stimulated to healthy action by its assist- 16 
INTRA-UTERINE THERAPEUTICS. 
ance. If the membrane is thickened and congested from 
the presence of a fibroid tumor, a careful curetting will re- 
lieve haemorrhage, perhaps for a long time. If there is 
bleeding on account of a villous, or papillary, or fungous 
condition of the endometrium, curetting will relieve it al- 
most to a certainty. The same condition may he relieved 
by the galvanic current, but not more efficiently as a rule. 
If the mucous membrane is merely thickened or hyperplastic, 
a careful curetting is the most efficient way to stop the su- 
persecretion of the glands and remove other symptoms 
dependent upon the condition. In malignant disease of the 
endometrium the curette is of the greatest value if a radical 
operation is not to he performed. It is well to follow its 
use with that of the actual cautery, or a powerful caustic 
like the chloride of zinc. As to the fo.rm of the curette to 
be used, the dull wire may be employed if the tissues to be 
removed are not dense or abundant, but it bends readily 
and is comparatively useless if the disease is very extensive. 
The sharp steel curette is an instrument which is not with- 
out great danger, but, if one remembers this fact and under- 
stands the tissues he is operating upon, it will often prove 
invaluable—a friend from which one would not readily part. 
Auvard has recently devised an instrument with which 
curetting and irrigation can be performed at the same time, 
and the ecouvillon or bristle brush of Doleris, with which 
the debris from curetting can be removed, is well known. 
Neither of these instruments has come into general use in 
this country. 
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2. BECAUSE : It is the exponent of the most advanced scientific 
medical thought. 
3. BECAUSE : Its contributors are among the most learned medical 
men of this country. 
4. BECAUSE: Jts “Original Articles” are the results of scientific 
observation and research, and are of infinite practical value to the 
general practitioner. 
5. BECAUSE : The “Reports on the Progress of Medicine,” which 
are published from time to time, contain the most recent discov- 
eries in the various departments of medicine, and are written by 
practitioners especially qualified, for the purpose. 
6. BECAUSE : The column devoted in each number to “Therapeu- 
tical Notes” contains a resume of the practical application of the 
most recent therapeutic novelties. 
7. BECAUSE : The Society Proceedings, of which each number con. 
tains one or more, are reports of the practical experience of 
prominent physicians who thus give to the profession the results 
of certain modes of treatment in given cases. 
8. BECAUSE : The Editorial Columns are controlled only by the 
desire to promote the welfare, honor, and advancement of the sci- 
ence of medicine, as viewed from a standpoint looking to the best 
interests of the profession. 
9. BECAUSE : Nothina is admitted to its columns that has not some 
bearing on medicine, or i3 not possessed of some practical value. 
XO. BECAUSE: It is published solely in the interests of medicine, 
and for the upholding of the elevated position occupied by the 
profession of America. 
Subscription Price, $5.00 per Annum. Volumes begin in January 
and July.