as the risk of perforation of the uterine wall is concerned. I shall pass these around, not that any novelty attaches to them, but it had been thought that a personal handling might better enable us to appreciate the relative merits of these two curettes and I hope that we may be induced to make more frequent choice of the dull one, especially in the class of cases now under notice. I have often remarked that the sharp curette, like the old-time thumb lance, has in ignorant hands slain its thousands! Possibly I have stretched the truth in this assertion, but seriously I am quite sure that there are many fatalities thus caused which will not be made known until the judgment day!

In his excellent work on gynecology, Dr. Emmett, referring to the curette, first devised by Recamier, and his successors, makes the declaration "That as regards the sharp instru ment of Dr. Sims, I honestly believe that the ingenuity of man has never devised one capable of doing more injury." This same author it seems had for years realized the danger attending the use of the sharp curette, and in 1863, devised an instrument which he called his curette forceps, and which in his hands seems to have met the demands with a reduction of risk attending the use of the ordinary curette, but in the hands of others it has not been satisfactory, and has long been discarded.

The cavity of the body of the unimpregnated uterus was once a sacred territory that few dared to invade. But finally it became a selfimposed duty of every one to scrape it thoroughly upon the slightest evidence of infection. Now, there is nothing sacred about the empty uterine cavity. It is invaded at will with impunity, but not without cost and this sometimes most serious. Women have been womb-scraped to death, -curettes have punched holes through

the uterine wall into the abdominal cavity, and many a time an innocent enough and simple endometritis has been converted into some dangerous septic infection by an unclean curette when expected to do good instead of harm.

We are altogether too apt to run to extremes nowadays and to the most absurd extremes at that. Yet, a very few seem to care. Patients do not or cannot understand, while regular doctors are too busy doing much for the little they get, and so depend almost entirely upon enthusiasts and theorists and faddists. The object of curetting the uterus when sifted down to the last analysis is to scrape away with a microscopic implement a microscopic object. Think of it a moment! And we make ourselves believe that we do that very thing, but we don't. We scrape, to be sure, but we do not get away all the disease germs. We do not even get away all the affected endometrium, for to do so under the circumstances is a complete physical impossibility. To verify the truth of this assertion, examine post-mortem, the uterus of any woman who has been curetted and note the invariable remnants hanging in sections and streaks of portions of the endometrium which had been plowed up by the instrument, whose primary name meant "to cleanse!" This appearence is manifest to the naked eye. Then observe closer this torn-up surface and see more with a magnifying lense. Then finally study sections under the microscope. After this ask what good does curetting do, in these cases and if any, how? There is food for sober thought in these two questions, and a good head that is honest with itself cannot give a satisfactory answer based on any of the well-known data. The fact is that we have gone too far again in this as in most other things. We have half seen a new thing or truth or

old one in new dress, only to straightway over apply it. And then we add insult to injury by abusing all who do not at once agree with our dictum. Finally, we are brought up with a round turn, admit our error possibly, but learn nothing from it otherwise, for we do the same thing again in another way. The above remarks upon the abusive eyils of a reckless use of the curette have been suggested that the profession may be induced to depend more upon irrigation and to a less frequent use of the currette in the class of cases under discussion. The admitted fact is that the presence of a putrid mass within the cavity of the uterus is a continuous source of infection, that saps and drain the already depleted system of the energy of its possessor in the effort to overcome its poisonous effects. The removal of such noxious material has almost always been followed by a prompt recession of the bad symptoms it had caused. If fol

lowed by a cleansing antiseptic

douche to carry off all detached smaller pieces and fluid and semifluid leavings, nature has generally proven herself able to take care of the rest. Free drainage in these cases was regarded at one time as of the more essential object than any other one thing. But those who observed the good effects of removal of the mass, like the dull patient, who imagines that the swallowing of a whole bottle of medicine at once will cause a more rapid cure, thought to expedite matters by the radical removal of all offending material, even the smallest vestige. But they do not seem to realize that in attempting this it is only an attempt, because physically impossible of accomplishment, they scrape away in fact such efficient barriers against infection as nature had already erected. Then the mischief is done and with the gates down, infection has ready

ingress and he reason that more deaths do not follow the excessive, I might say, reckless use of the curette, is because of the saving effect of intra-uterine douching with suitable antiseptics. Mind you, I am only speaking in reference to curettments in septic cases and no reference whatever is had to its use on other legitimate occasions. However, even in such other cases as are plainly fitted to its use, should the curette be employed and then under the strictest antiseptic precautions. I mention in this connection cases of unavoidable abortions and chronic endo-metritis, which with a few other unusual conditions, make up the list.

I have been making use of the reflux intra-uterine irrigator in my practice since 1880, and while I have applied it in all septic or toxico-genetic troubles, it is in the puerpera that its beneficial effects have been the most apparent. The following reports will serve to demonstrate the line of procedure and how the passing experience had developed my present plan of treatment, which I must say has been eminently satisfactory. The first was a case under the care of Dr. T. J. Estill, Missouri, now of Colorado Springs. This case was that of a farmer's wife, who had been delivered of a healthy child in the spring of 1880. The doctor having detected septic symptoms two days after the delivery, and having heard of my good success with the intra-uterine irrigations (which, by the way, was the first of its kind to be used in that section,) had me called to see what it would accomplish in such cases. I found the patient in a clean bed and surrounded with all the comforts of a pleasant home, but with a temperature of 104 degrees, pulse 120, flushed face and with a fetid discharge of lochial matter, bowels tender and tympanitic, but no excessive symptoms of peritoneal inflammation. At

the doctor's request, I introduced the irrigator and thoroughly washed out the womb with a strong solution of warm carbolized water, at a temperature of 100 degrees.

After waiting about an hour the doctor placed the thermometer under the tongue and to his surprise and delight it registered 100 degrees, and with a corresponding fall of the pulse rate, and perceptible betterment of her condition generally.

The patient continued receiving these flushings, about every three hours for a week, when all signs of fever had passed and the fetid discharge had stopped. She made a good recovery and was soon out of bed. The curette was not used in this case. Since that tire and up to the year 1895. I had continued this same general line of treatment in my own practice, as well as in consultation with other physicians with varying results and several deaths.

On April 16, 1895, I was called to see Mrs. L., a sailor's wife, in consultation with Dr. Crawford, now of Santa Monica. Patient had been having strong labor pains for the past twen'ty-four hours, this being her first confinement and as there had been but little progress for several hours with head pressing upon the perineum and her strength lagging, it was thought best to apply the

orceps,

which I did at the request of the doctor, he administering the anesthetic. There was a laceration of the perineum and which was repaired soon after the child was born.

There was slight fever at the termination of this labor, but nothing specially noteworthy, yet sepsis of a violent form set up on the third day, at which time Dr. A. Davidson, now of Clifton, Ariz., was asked to see her in consultation, when it was the concurrent opinion that her chance of recovery was very slight and that she would not survive more than forty

eight hours, unless relieved. This was the fourth day of her puerpera, and on that evening the attending physician and I concluded to try intra-uterine injections. The irrigator was passed well up to the fundus and by means of the fountain syringe the cavity of the womb was thoroughly washed out with carbolized water at temperature of 100. This was repeated every two or three hours for twenty-four hours, but with little benefit, when, at my suggestion, the expedient which I now invariably employ, that of flushin- the uterine cavity first with the carbolized water by means of the reflux irrigator attached to the fountain with a fall of two feet and while the irrigator is still in the cavity of the uterus the tube of the fountain is detached, and which should be elevated about fourteen inches above the end of the irrigator, and through this funnel is poured a "little at a time," pyrozone or the peroxide of hydrogen, half an ounce, and after each addition, time should be given for chemic action, which will be manifested by the escape of gas bubbles. After this has ceased more of the pyrozone should be added and this should be repeated several times at each washing. This procedure should be repeated every two or three hours, always preceded by the thorough cleansing of the cavity of the uterus with carbolized hot water. When it can be done without too much disturbance to the patient, it is well to have her sit up in bed so as to allow the residuary water to escape from the vaginal cavity, so that the action of the prozone may not be diluted, thereby as to its good eífects.

I must say that the benefits of this procedure in this case was very satisfactory indeed and the improvement was promptly manifest by the lowering of the temperature, better pulse beat, and in many ways were its good

effects assuring and gratifying. In this one instance, as well as in a score of similar ones, in my own and also in the hands of other physicians whom I had assisted. I take liberty to refer to one such in the hands of my friend, Dr. Perry of Corona, Cal., where Mrs. K. of that village had been confined with first child. I saw this case the fourth day of her lyingin, on account of a violent septic

infection, which had set in soon after the child had been orn.

The doctor had been applying the usual remedies and seemingly with very little benefit. I suggested the above line of treatment, which the doctor very efficiently and faithfully continued for about a week with the best of results, when it was deemed by him that further irrigations were unnecessary. This case, so forbidding, made a good recovery, and while she was slow in her convalescence, she finally recovered and is as well as ever If permitted to further speak of my personal sucess in this manner of treating this of all others, the gravest puerperal malady that we have to deal with, I would say that SO far as my knowledge extends; there has not been a single death during this period, which now covers a space of seven years, and had to do with at least a score of cases in all. It is simply remarkable to witness ne prompt betterment of the grave conditions, and that, too, within such a short time after the irrigation had been used. I usually accompany this irrigation by tonics, and as liberal nourishment as the stomach will llow.

In closing this paper, I must say

that I do most emphatically deprecate the fact that the curette has been, and still is being greatly abused in many hands. The truth is that it should be used less often, and less vigorously and that more reliance be placed upon the stimulating, unirritating intrauterine douche, and free drainage preceded always by the thorough re'moval of all infected masses that can be taken away without injury to the normal structures and with subsequent liberal antiseptic irrigation repeated as indicated, free drainage, and bearing in mind that seldom, if ever, is it wise to scrape down to the muscle of a uterine wall in infectious cases. The destruction of the endometrium may be wise for other reasons, such as removal of fungosities and for menorrhagia and metrorrhagia, to stop the persistent hemorrhages and leucorrhoea in these maladies. We should not forget that mucous, like external cutaneous structures, are constructed to antagonize infectious processes. Muscle tissue has its absorbing lymphatics, but it is devoid of the elements of successful defence existing in the mucosa. Hence to scrape away the endometrium opens up the lymphatic channels for the ready unobstructed conveyance of disease germs and chemic poisons to the circulation, and I may say that with few exceptions, the dull curette should be the one used for reasons above given.

Douglas Building. Roome 411-412-414.

(1.) Read by request, before the Academy of Medicine, and also at recent meeting of the Los Angeles County Medical Society.

The first and most important fact that stares us in the face when we are called to see the patient is that when once infected by thebacillus of Eberth, he must pass through a period of illness that will depend upon the virulence of the infection, his suceptibility, or partial immunity to the germ, and what little we may do to modify the disease by assisting in support of the patient, and the use of such measures as tend to control the formation of toxins and the attendant pyrexia, and assist nature in elimination, and the restoration of the body to a normal condition.

The expression so often heard among the laiety of "breaking the fever" will never be used by the intelligent physician in speaking of typhoid. For the apparently aborted cases still show the presence of the disease when the Widal test is applied for days, and even weeks. The best we can do is, like the pilot to guide the storm-tossed ship into smooth waters, as soon as possible, and ultimately to refuge in a safe harbor.

The "management of typhoid" not only pertains to the patient alone, but in a disease so manifestly infectious or communicable to the attendants, the family, and the public in general.

That typhoid fever, by proper hygenic and sanitary measures, can be controlled to a greater extent than any other infectious disease, is beyond question; and it is as much the duty of the attendant physician to give proper instruction tending to prevent the spread of the disease as to care for the patient. Numerous epidemics are of record due to gross, if not criminal lack of observance of the laws of health and sanitation. In cit

ies like ours that have good water and sewer systems, there should be practically no typhoid except that which is brought in from outside sources of infection, and it is a fact, that a large percentage of our cases are due to the later cause (45 per cent. according to a statement of Dr. Powers, City Health officer, in a paper before the county society, June, 1900.)

As food and drink are the chief source of infection, the prevention of their contamination is of first importance, and to get at the root of the evil, by sterilizing all dejecta, both fecal and urinary, bedding and wearing apparel, cups, spoons or other utensils that may lead to infection, direct or indirect, we will accomplish more than by depending on the later precaution of boiling the drinking water, sterilizing the milk, and thoroughly cooking all vegetables liable to infection by sewerage, etc.

For the safety of herself, and others, the nurse should observe the rules of asepsis and antisepsis as rigidly as were she nursing a surgical case. It is not sufficient to throw a little chloride of lime into the vessel to receive the discharges, but at least a pint of solution of some active disinfectant, such as the above, formalin or corrosive sublimate should be used and thoroughly mixed with the dejecta and let stand a sufficient length of time before emptying, to kill all germs that may be a source of future trouble. All infected clothing, napkins, etc., should be either boiled, sterilized by dry heat or burned.

In reference to treating the discharges with germicides, it is fully as important to sterilize the urine as it is the feces. Pettruschky has estimated that as many as 172,000,000 ba