The Blunt Curette in Uterine Haemorrhage. BY f THOMAS W KAY, M. IX, SCBANTOn7'pAm EX-SURGEON TO THE JOHANNITKR HOSPITAL AT BEYROUT, SYRIA. EEPRINTED FROM SEbe Neto ¥ovfc fWetocal journal for November 1889. Reprinted from the New York Medical Journal for November 2, 1889. THE BLUNT CURETTE IN UTERINE HAEMORRHAGE. By THOMAS W. KAY, M. D., SCBANTON, PA., EX-SUBGEON TO THE JOHANNITEB HOSPITAL AT BEYBOUT, SYBIA. In a paper read at Newport, June 27th, Dr. Georges Apostoli, of Paris, in lauding the use of electricity in uterine affections, remarked that the curette had fallen into desue- tude in France, the place of its birth, and he intimated that the doctor of to-day who still stuck to its use had not kept pace with the advance of gynaecological science. That electricity is an important agent in the treatment of uterine troubles no one denies, and we are chiefly in- debted to the care, industry, and perseverance of Dr. Apos- toli for our present knowledge of its therapeutic value; but it is not applicable in all cases where the curette can be used, and in some where its application is suitable it gives no better and not as rapid results. The use of the curette is best limited to those troubles arising from disease of the endometrium, while that of electricity should be limited to those affections arising from disease of the parenchyma or the appendages of the uterus. Each of these fields overlaps the other to some extent, and here either agent can be used indifferently. 2 THE BLUNT CURETTE IN The bleeding caused by fibroids of the uterus can be arrested by the curette, but we do not get the diminution in the size of the fibroid that is obtained by the use of elec- tricity. Metrorrhagia, due to degeneration of the endo- metrium, may be cured by electricity, but it takes more time and the results are not more satisfactory than those given by the curette. But the curette is as inapplicable in salpingo-ovaritis as is electricity in uterine polypi. The field of each is pretty sharply defined, and the closer each agent is confined to its own sphere, the better will be the results obtained. The present tendency in America seems to be to ignore the blunt curette in all cases where the sharp curette can be used. This is bad practice, for denuding the uterus of all of its raucous membrane is no small matter, and with the sharp curette this can be done not only where the mem- brane is diseased, but also where it is healthy. With the blunt curette, however, it is only the diseased portion of the membrane that can be removed, while the uterine glands are emptied of their contents. Where we wish to remove a small piece of the endometrium for diagnostic purposes we find nothing to take the place of the sharp spoon ; and in intra-uterine growths of long standing, where the bases are broad and firm, the sharp curette will be found to be indispensable. When, however, we have to deal with growths of recent formation, as in the case of retained pla- centa or placental polypi, or where we have a degenerated condition of the mucous membrane, all that is necessary can be removed by the blunt curette, after which a strong styptic should be applied to arrest the bleeding and produce a healthy action on the endometrium. Practically speaking, all diseases of the endometrium in which the blunt curette is applicable have the one common manifestation of haemorrhage. This may be constant or UTERINE HEMORRHAGE. 3 periodical, profuse or moderate, and from various causes, which can be best illustrated by giving the histories of a few typical cases. It will be best, however, to say first a few words about the use of antiseptics and the dilatation of the uterus. Bearing in mind the direct communication between the uterine and abdominal cavities, and how richly supplied the uterus is with absorbent vessels, the greatest care should be used in all operations on that organ to pre- vent infection. The vagina should be thoroughly cleansed before all operations on the endometrium, and both uterus and vagina after. This can be done by solutions of per- manganate of potassium, carbolic acid, corrosive sublimate, or creoiin. Of these, creolin is probably the best, though I have got excellent results from the solution of the perman- ganate, as I ha\e also done from simple hot water. For all operations on the uterine cavity a dilatation of the cervical canal is necessary. Where intra-uterine growths exist, the canal, as a rule, will be found more or less patulous, and here rapid dilatation will be found most suitable. Any of the many ingenious uterine dilators can be used for this, but I find a set of steel urethral sounds among the best. Drawing the cervix well down with a volsella, these are passed singly from the smallest to the largest, when a re- turn to the moderate-sized ones is made, and two or more passed together till sufficient room is obtained. If the cer- vical canal is normal in size, or nearly so, as is generally found in degeneration of the endometrium, rapid dilatation causes too much bruising and injury to the cervix; so here it is better to dilate gradually by means of tents-lamina- ria, sponge, slippery elm, or tupelo. Of these, the tupelo is much the best, though requiring more time than the sponge. Anaesthetics can be used or not as is deemed best by the operator, but in most cases, where the patient is of a 4 THE BLUNT CURETTE IN nervous temperament, their administration will be found to ward off complications. In all cases absolute rest should be enjoined for some days after the operation, for it not only prevents accidents, but it favors the return of the uterus to its normal state. Some of the following cases were operated upon quite a while ago, but they are selected as types, showing where the blunt curette can be used : Case I. Endometritis with Sub involution.-In November, 1879, I was called to see Mrs. M. J., twenty-six years of age, who was a resident of Baltimore. Eight months previous to that time she had had her first child, since which time she had suf- fered more or less from haemorrhage. During the last month this had become so profuse that she was compelled to take her bed, and was then too feeble to be around. Examination re- vealed a retroverted uterus, much enlarged and tender. Sound- ing was exceedingly painful, and gave a depth of four inches. After the parts were thoroughly cleansed, a small sponge tent was inserted and allowed to remain for ten hours. On the re- moval of the first, a second tent was introduced and allowed to remain till the following morning, when it was removed, and the uterine cavity carefully examined with the finger, but nothing abnormal could be found except a softened and thick- ened condition of the endometrium. This was thoroughly cu- retted with a blunt curette, after which liq. ferri subsulph. was applied to the whole cavity. From this time on the haemor- rhage ceased, and in one month sounding gave a depth of three inches and a quarter. This case illustrates well a common class, where the trouble dates back to childbirth, and is probably due to improper care and a too early return to household duties. Case IF. Fleshy Mole.-Mrs. J. B., of Columbia, Pa., sent for me to see her in September, 1880. She was twenty- nine years of age, the mother of three children, and supposed herself again pregnant. The previous April her menses failed UTERINE HAEMORRHAGE. 5 to-make their appearance, but during July and August there was a slight show of blood. When called, she seemed to be suf- fering from labor-pains with considerable bleeding. On exami- nation. the uterus was found as large as the fist; its cervix was rigid, but its canal was large enough to admit the tip of the finger with difficulty. A firm, fibrous mass could be felt pre- senting at the internal os, and as this in no way resembled the nor- mal product of conception, the cervix was drawn down with a volsella while the uterus was dilated with the finger. The mass was nearly as large as a hen's egg and pear-shaped, being attached by its base to the posterior wall of the uterus near its fundus. This was removed with some difficulty by the blunt curette and a solution of permanganate of potassium used to irrigate the cavity. Recovery was rapid and complete, the woman having since borne children. Though the mass pre- sented no placental structure, it was undoubtedly the product of a blighted ovum and had probably become attached to an in- flamed endometrium, thus escaping expulsion. Case III. Retained Placenta and Membranes.-In June, 1881, I was called to see Mrs. F. II., of Columbia, Pa., a mul- tipara. who had three days before been delivered by a midwife. The cord and only part of the membranes had come away, and, as the discharge had become very offensive and there was con- siderable fever, I had been sent for. Before examining, the vagina was irrigated with hot water, when the uterus was slowly dilated with the fingers and the placenta found firmly attached posteriorly and above. About half of this was re- moved with the hand, but some portions were so firmly attached that the blunt curette had to be used. Finally, all was removed and the cavity presented a uniformly smooth surface, after which it was irrigated with a hot solution of potass, permang. Recovery was uninterrupted, and in ten days the woman was attending to her regular duties. Prompt interference here probably saved the life of the mother, as there were marked symptoms of blood poisoning ■when I was called. Case IV. Degeneration of the Endometrium near the Meno- pause.-In December of 1881 I was called in, by her attending physician, to see Mrs. M. A., of Columbia, Pa., an invalid 6 THE BLUNT CURETTE IN mother of several children. She was forty-seven years of age, and had suffered irregularly for eighteen months from metror- rhagia. During the last month the hasmorrhage had become very profuse, and, as it did not yield to internal remedies, opera- tive interference was deemed expedient. The uterus was found to be slightly enlarged, tender to the touch, and very flaccid, but normal in all other respects. A tupelo tent was introduced, and the following day a larger one was substituted, which in twenty-four hours gave sufficient room for the finger. On ex- amination, the endometrium was found to be thickened and soft, so that shreds of tissue could be easily removed with the finger, but no growth of any kind could be found. A teaspoonful or more of degenerated tissue was removed by the blunt curette, after which Monsel's solution was applied to the cavity. For some days there was a slight discharge of bloody water, but this ceased in a short time, and after a month the woman, though still feeble, suffered no more from haemorrhage and was much improved in health. Case V. Incomplete Abortion at about the Third Month.- Hannah, a multipara, thirty-two years of age, presented herself at the Johanniter Hospital, in Beyrout, Syria, in November, 1887, to be treated for corneal ulceration and partial staphyloma. A solution of atropine was instilled into the eye and subsequently the portion of prolapsed iris removed. Three days later she was taken with pains and haemorrhage from the womb, when she informed me that she thought herself about three months preg- nant. The womb was found as large as the fist, with the cervix sufficiently dilated to admit Jhe finger to the internal os. This was found partly dilated, with the uterine contents presenting. As haemorrhage was profuse, the pains strong, and all hopes of preventing the catastrophe passed, the cervix was drawn down with a volsella, the canal rapidly dilated with the fingers, and the uterus emptied of its contents with a blunt curette. As the uterus was now well contracted, the vagina only was washed out with hot water and rest enjoined. Recovery was rapid and without complications. This is undoubtedly the best treatment to adopt in all cases of incomplete abortion, though strenuously opposed by some good authorities. UTERINE HAEMORRHAGE. 7 Case VI. Placental Polypi of Several Months' Standing.- During March, 1889, I was called in consultation by a physician who was attending Mrs. C. P., of Baltimore. She was a multi- para, some thirty-eight years of age, and had miscarried several months previous to the consultation, since which time she had suffered from bleeding, that became profuse on the least exer- tion, but almost ceased, to give place to leucorrlioea, when she was quiet. The uterus was several times its natural size, and the cervix was sufficiently dilated to admit the finger as far as the internal os. Rapid dilatation was undertaken and accom- plished in a short time, with urethral sounds, and three poljpi of moderate size were found attached to the posterior wall near the fundus. These were removed with ease by the blunt curette, the haemorrhage arrested with Monsel's solution, and the vagina irrigated with warm water. Several hours after the operation there was a severe chill with a sharp rise of temperature, but by the next morning all bad symptoms had passed and she made a rapid and complete recovery. ft REASONS WHY Physicians Should Subscribe F0R The New York Medical Journal, Edited by FRANK P. FOSTER, M. D.,5 Published by D. APPLETON & CO,, 1, 3, & 5 Bond St. 1. BECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 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: Its "Original Articles" are the results of scientific observation and research, and are of infinite practical value to the general practitioner. 5. 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