The risks resulting from the use of the curette and of the sharp scoop have often been over stated. Recamier's curette, which we do not highly endorse, has, however, in the hands of the inventor and of Demarquay, perforated the uterus in five instances, but the flexible Sims curette and Simon's scoop, are hardly likely to do this if used with care, where the tissue of the uterus is sound and the instrument is only used as a curette. In case, however, the tissue of the uterus is soft., as during the puer perium, or if the walls of the organ are more or less implicated in the new growths, then the greatest possible care is requisite lest perforation occur into the peritoneal cavity. Of the few reported cases of perforation with Simon's scoop (the cause of the two deaths in the practice of Martinez del Rio is not known to me), in Spiege)berg's case there existed carcinomatous degeneration of the entire thickness of the uterus. Although the result was not fatal, I also perforated the uterus while curetting a rapidly growing vascular sarcoma seated in the posterior wall of the organ. Generally, however, as the result of irritation from the curetting, the organ contracts so forcibly that the curette or scoop creaks as it passes over the surface, even as it would if scraping a bone. The same sound, however, is yielded by new growths which consist of dense, connective-tissue stroma, and also in the cervical catarrh accompanied by hyperplasia of the plicEe, and therefore we cannot feel sure that all masses have been removed when the creaking sound is heard or no more masses are removed.
A necessary postulate for the resort to the operation is the accessibility of the diseased surface to the sight or to the touch. In case of the exter nal genitals, the vagina and the cervix, this condition is fulfilled, seeing that the speculum may be used or the parts are within reach of the finger. The uterine cavity, however, must often be previously dilated by the bloody or non-bloody means. The question as to the necessity of prelim inary dilatation depends on the diagnosis and the nature of the requisite manipulation. It is preferable to work with the finger and the curette at the same time, and this is especially requisite in the removal of small tumors at the fundus or tubal openings, or when the curette forceps are used. In the majority of instances of chronic endometritis, however, even though the entire endometrium must be curetted, we are generally able to do so without much dilatation, for it suffices if the curette can pass through the cervical canal. Enough dilatation may be obtained in these instances by the tube which is used for irrigation. Preliminary dilatation may be secured by tents, steel-branched dilators, or by discis• sion. Rules in regard to the choice of these methods cannot be formu lated, since they vary with the special nature of the case. Even exten sive dilatation of the cervical canal, however, sometimes is not sufficient to enable us to feel the neighborhood of the orifices of the tubes, and yet it is here that vegetations are specially situated. We acre then obliged to
depend on the sensation communicated by the curette or the sound. If we are unable directly to watch the action of the curette with the finger, then the finger should be placed in the vagina to control the action of the instrument, or in the rectum when the scraping is on the posterior wall, and in the anterior rul-de-sac or in the bladder when the anterior wall of the uterus is being curetted. We may thus estimate the thickness of the uterine wall and note the liability to perforation. These procedures have the further advantage that thereby the organ is steadied so that the curette may be used on a firm base.
To use the curette, the bowels and bladder should be emptied and the patient should be caused to assume the dorsal or the lateral position. A large disinfectant injection should be administered, or the vagina and uterus may be permanently irrigated during the procedure. Where there is lack of spree for the coincident irrigation of the uterine cavity, it should at least be washed out through a return-current catheter, for the purpose of disinfection and of removal of the curetted fragments. By means of the irrigator-curette we can readily attain these aims, only clue must be taken that, during the use of the instrument, the supply tube is not twisted or compressed. Curetting may also be resorted to through the .Bandl or the short Cusco speculum filled with 5 per cent. carbolic or sublimate solution.
The part to be curetted should be steadied by assistants through ten acula, and drawn down a trifle, and this may often be well accomplished by two fingers in the rectum. Under the guidance of the finger, or else through a speculum, the curette is applied to the desired spot or is in serted into the uterine cavity. In the vagina, straight or slightly curved instruments generally suffice, but for the anterior and the posterior uterine walls the instruments must be sharply curved. The fundus is beat curetted by instruments, the cutting part of which is at right angles to the blade.
In case we aim at curetting new growths, large scoops should be chosen at the outset in order to remove quickly the in general vascular growth, such as carcinoma. The curette is drawn backward and forward over the diseased surface wherever the finger has detected alteration, and the manipulation is kept up until the scraping sound tells us that we have reached uterine tissue. After the process is at an end, we should examine again with great care to see if any remnants are still to be re moved. If this be the case, then a smaller instrument is inserted and the process repeated. In case we aim purely at curetting the mucous membrane, and the cervical canal, as is usually then the case, is not wide open, then a small instrument should be selected at the outset.