sions I thought it best to give a dose of opium; but the colios were never sufficiently violent to cause apprehension.

These injections of Churchill's tincture promptly arrested the bleedings, as well as the leucorrhoea, and menstruation became normal; the patient gained flesh, she had been quite nervous and restless, but now slept well, ate well, and took long walks with impunity. I repeated these injections about once a week (two or three times between her periods) for some weeks. I then stopped all treatment, and from the middle of May to the middle of July she remained perfectly well, when the weather being extremely hot she went up into the mountains of New Hampshire, where she remained two months more, perfectly well, when the metrorrhagia returned, though with less violence than when I first commenced treating her. About the middle. of November of the same year, nine months after she first came under my charge, she returned to New York, and again applied to me for treatment. I now came to the conclusion that there was some morbid condition of the cavity of the uterus, which was not to be reached by the class of remedies I had so faithfully used, and therefore determined to dilate the cervix, explore the cavity with the finger, and determine if possible what was the cause of the continued hæmorrhages. For reasons which I need not state, two months were allowed to pass without carrying out my idea; but early in January the renewal of treatment was determined on, and I asked my friend, Dr. J. Marion Sims, to see her with me. The Doctor agreed fully with me as to the necessity of exploring the uterus, and on the afternoon of the 18th of January, 1871, I introduced a spongetent, which I removed the next morning at 10 o'clock; this was removed and a larger one introduced, in the expectation that by 4 o'clock in the afternoon, the cervix would be sufficiently dilated to allow the finger to pass the internal os. We met at the appointed hour, removed the tent which had been inserted two and a quarter inches, but much to our disappointment, in consequence of the elongation of the organ, the tent was not quite long enough; and although the cervix was very

fully dilated up to that point, the internal os was only partially so, and did not permit the finger to pass well through.

We had determined to explore the cavity, to determine whether there was a polypus or vegetations, and if the latter, to remove them at once with the curette of Dr. Sims. The Doctor introduced the curette, and the first scrape fixed the diagnosis by bringing away several vegetations; he then continued scraping the surface in every direction, and succeeded in removing about a tablespoonful of vegetations, some of which were an inch or more in length, about the size of a crow-quill, and resembling very much an earth-worm, such as boys use for bait in fishing; others were less elongated, either sessile or pediculated, and ranging in size from a grain of wheat to a buckshot. No hemorrhage followed the operation, which was accompanied by a good deal of pain, but the pain ceased as soon as the curette was laid aside. She continued quite comfortable for twelve hours, but became restless in the latter part of the night, and about 3 o'clock in the morning had a chill, which lasted for two hours, followed by fever. The fever ran pretty high, accompanied by a good deal of uneasiness in the pelvis, but went off with free perspiration in about thirty-six hours. I put her at once on the free use of quinine, and she had no fever for a week, but did not feel comfortable when she sat up for several days after the fever. The curette was used on the 19th of January, and at the end of eight days, I perhaps imprudently allowed her to go out and take a walk. She was in the habit of much out-door exercise; did not sleep well, and lost appetite whenever much confined to the house. The weather was cold and unfavorable, and on account of the crowded state of the omnibus at the time, she could not get a seat home, and was forced to walk some three-fourths of a mile, got her feet cold, and came home fatigued. That night she had fever again, with pelvic pains, which lasted forty-eight hours.

February 1st. This morning her fever is gone, and she feels quite comfortable. I omitted to mention that her menstrua

tion came on about six days after the use of curette, lasted five days, without excess or pain.

February 4th. She is not comfortable out of bed, and on examination, by touch, I find the uterus engorged, the body retroverted (which it was before more or less), and very tender to the touch; a little thin mucous, and sometimes sanious discharge.

I put her on one-sixteenth of a grain of bichloride of mercury, with three of iodide potassa and two drachms of Huxham's tincture cinchona three times a day.

February 6th.—I find her more comfortable, though still in bed, and engorgement of uterus decidedly less. Complains of disagreeable taste in mouth; I ordered the dose of medicine to be diminished one-half, fearing salivation might occur, though I have never salivated a patient in my life with the corrosive sublimate, which I often give.

She continued gradually to improve up to the 24th, when the menses again came on. The enlargement and tenderness of the uterus has gradually decreased, but she has felt some little uneasiness about the back and pelvis whenever she walked about her room.

March 4th. The menstruation continued but three days, and without any discomfort, and what is remarkable since the first four days after the use of the curette, she has had not the slightest discharge of any kind from the uterus. She went out three days ago to take a little walk, and had the next day a severe nervous headache.

The uterus now seems to have gone down to its normal size for the first time since I first saw her twelve months ago, and as far as position, function, size, feeling to the touch, etc., the organ seems to be in good condition, still there is sensibility about the organ or its surrounding tissues which causes uneasiness in walking, and which has been followed by increased complaint and febrile action every time she has attempted exercise. The most rigid examination can discover no swelling nor tenderness about the broad ligaments or surrounding tissues.

March 15th.-Though she still has backache when she walks, her health is good, all the functions are active; there is no discharge of any kind, and she looks like one getting well.

This case demonstrates the importance of basing the treatment of metrorrhagia not upon the symptoms, but upon its pathology. The intra-uterine remedies which I employed in the early part of the treatment arrested the hæmorrhages for about five months, in consequence of which Mrs. B. regained her flesh and health, and to all appearance was cured. The vegetations which gave rise to hæmorrhages were for the time arrested in growth, and so modified in character as to relieve the symptoms, but the faithful application of persulphate of iron, carbolic acid, and iodine, did not eradicate the growths, and when the symptoms reappeared the same remedies had no power to arrest the hæmorrhage. The disease had only been palliated, and not cured. It is possible that the concentrated chromic acid (as used by some gynecologists) might have destroyed the morbid growths, but having seen bad symptoms follow the use of this remedy, I was reluctant to resort to it. The choice lay next between chromic acid and the curette, and I must say, judging by the number and size of the vegetations, that nothing short of the curette could have reached the difficulty.

I confess that my own experience with the curette has not been large, and my opinions have been formed as much by witnessing its action in the hands of others as my own.

If we turn to the writings of French, English, and American gynæcologists, we find the extremest diversity of opinion as to the value and safety of the curette. Some condemn it as barbarous, while others recommend it in unmeasured terms; and, as generally happens, the truth will be found to lie in the middle. Another important question arises as to the best and safest form of curette. Some use that of Recamier, which is a miniature lithotomy scoop. Dr. T. G. Thomas, who is excellent authority, uses a scoop made like a loop of strong wire, which rakes off the soft vegetations without attacking the mu

cous coat of the organ. This, he asserts, acts with sufficient thoroughness. Dr. J. Marion Sims says that such an instrument is not efficient, and that the uterus cannot be sufficiently cleared of the morbid growths without employing a more cutting instrument. He has therefore contrived a curette in the shape of a small elliptical ring, attached to a long malleable. shank with a handle, which presents a sharp circular cutting edge, and made to scrape like a gardener's hoe, or currier's knife. The cutting edge, however, is set on at an obtuse angle with the shank, so as to scrape off the vegetations without cutting into the mucous tissue. It requires, however, great tact to regulate the pressure so as not to remove the mucous lining of the uterus, as I have had occasion to see more than once in the most skillful hands. This instrument of Dr. Sims is certainly the most efficient in removing the vegetations, but is strongly objected to not only by Dr. Thomas, but by Dr. Nogerath, Dr. Peaslee, Dr. Emmet, and other New York practitioners, most of whom use a similar instrument, but with a very blunt instead of a cutting edge.

Leaving out of the discussion the danger of this scraping operation, it may be asked, does it permanently eradicate the growths it is intended to destroy? Are not the growths reproduced after a time with their attendant symptoms? Whether the vegetation be mashed off by a blunt instrument, or scraped off by a cutting edge, the effect on the bleeding vessels is that of an ecraseur-the hæmorrhage is at once arrested, and it is not likely to recur for weeks, months, or perhaps

never.

That the morbid growths do reappear in some cases is certain, and that chronic metritis does sometimes follow the operation when rudely done, I have had occasion to know more than once, in the practice of some of our leading gynecologists. I have now under treatment two such cases, operated on by others, and one of them of eighteen months standing.

In the present state of the controversy, my conclusions are decidedly as follows: