Botters and MuncW go further still, and not only resort to Veit's method, but proceed to curette the cavity of the uterus with Simons' scoop, or the metal curette of Thomas. They then similarly cauterize the endometrium.
[The author is here in error, certainly as regards Muncie's practice. It is not his custom, nor indeed of any of us in this country who practise interference because thereby the woman's safety is at once assured and.she herself not at all endangered, to use Simons' scoop, or any variety of sharp curette, for the removal of the retained placenta, or shreds of the ovum. The former, indeed, has devised the special instruments which we figure below, for the purpose of loosening the adherent placenta, and for its removal from the uterus. His curettes have no cutting edge, and are applicable to cases where there is a large Mit88 to remove, and where, in consequence, nearly always the cervical canal is wide open, and will hence admit them. Where we are dealing with small shreds, and the os is less patent, the dull curette of Thomas answers every purpose. As to whether the patient will be injured by such instrumental measures, or not, depends purely on the manner, and on the gentleness with which they are resorted to. The position of the woman should always be the left lateral, and the removal should always be through Sims speculum. Then the cavity should be carefully dried by a cotton applicator, and tamponed by means of the slide applicator, the cotton on which has been saturated in the compound tincture of iodine. These manipulations are painless, and if performed gently, even as every intrauterine manipulation should be, can do the patient absolutely no harm. On the contrary, she is spared the danger from profuse hemorrhage,.which might occur in the absence of the physician, and notwithstanding the ergot, she is spared the risk of septic infection, general or local, she is spared the mental anxiety to which otherwise she is subjected. Active intervention does not mean unnecessary interference. Nature is ever to be given a chance. But when we see that her efforts are futile, certainly it is but rational to assist her after a method which, rightly performed, bodes no barm to the patient, but is full of good. Those of our readers who have carefully studied the graphic pen pictures wherein Charpentier delineates the possible dangers which may, at any moment, follow on prolonged waiting, will at once agree that the procedure advocated in this country, particu larly by Mundt., is far preferable, if it be only free from risk, and this we are amply satisfied is the case. Miscarriage is fraught with more danger to the woman than labor at term, because, as Goodell aptly puts it, the process is like plucking immature fruit. We believe. however, that timely, active intervention, resorted to with care, will rob miscarriage of its dangers, and not at all substitute new ones.
Atnerican women, and German too, can stand the practice we advocate, not because they differ at all from the French, but because French accoucheurs, vrith scarcely any exception, have yet to learn the manner how to assist their patients rationally in case of prolonged miscarriage. —Ed.] Truly, indeed, as Pajot says, the German womb is very slug gish to be able to resist such treatment, which, further, it seems to us, is directly contrary to the aim of those who resort to it. Rlis objections are purely the result of the fact that the method of active intervention is not understood. That the sharp curette will wound the endome trium, we grant, but then the sharp curette is not advocated, certainly in this country; that deep cauterization of the endo metrium may in turn produce trouble, we grant, but then we do not argue for such cauter ization. The compound tinc ture of iodine is used as a gen tle styptic and disinfectant, and produces no slough, on the separation of which new hemor rhage will occur. We make these criticisms because our author, being opposed to active intervention, is not always just to the method. —Ed.) Views of those Opposed to Active Intervention.—The authorities who counsel waiting for the appearance of some complication before interfer ing, are just as many. We mention: Viasdel, Leboursier du Coudray, Lachapelle, Capuron. In England, Ramsbotham, Davis, Lee, Dewees, Ingleby, Burns, Blundell Fleetwood Churchill, Grainy Hewitt. In Germany, Honing, who advises resort to Kristeller's method of uterine expression, Martin, Kehrer, Hegar, Schroeder, Scanzoni, Spiegelberg. In France, all accoucheurs, except Gueniot, are in accord, and Cordes has stated the prevalent belief exactly, when he says: "MisCan-iage only ceases to be a physiological process, when the organism refuses to tolerate longer the placenta, and ceases to expel it, even as it will any foreign body. In other words, when uterine contractions supervene, when the patient loses blood, when tbe hemorrhage, or sero-sanguinolent discharge, is fetid—then, and then only, ought we to aid the failing force,s of nature." To resume, then, the practice we would recommend in case of mis carriage: A woman is miscarrying, the process is inevitable: tampon and administer ergot, against the hemorrhage. Remove the tampon at the end of twenty-four hours to thirty-six, if the contractions are feeble, at the end of eight to twelve hours if they are energetic. Then examine the cervix, being careful not to injure the °vim. If the ovum is engaged in the cervical canal, or if it be in the vagina, and if it is entirely detached from the uterus, this is a sine gud non, remove it at once; if the cervix is not sufficiently dilated, if the ovum has not engaged, if it is still adherent, in case of persisting hemorrhage reapply the tampon, and wait.