them a council of senators to whom we can appeal for advice and admire for its wisdom.

Amid the rejoicings and hearty greetings that mark our anniversary; along with the congratulations over the success that is attending the labors of this body to keep alive all things that pertain to the welfare of the profession, as well as over the honors and competencies that have followed as rewards of individual labor, there is forever present at our board a sorrow over the deaths of the honored and loved ones. The older ones have gone, and only their sweet memories are left as our guidepost to duty and success. These memories are, indeed, worthy of careful preservation, for they are redolent with all that makes up the honest man and the true physician. The younger ones have likewise now and again been called away, and we are to deplore their loss, snatched from our midst, when life was full of promise, and strength was happy companion of ambition. Loving hands will commemorate their virtues and good deeds, but it is fitting that we should remember them at this season, and in our sorrow know that we are better and more earnest men for their companionship.

Thou God of Love-beneath thy sheltering wings
We leave our holy dead,

To rest in hope. From the world's sufferings
Their souls have fled.

Oh! when our hearts are burdened with the weight
Of life and all its woes,

Let us remember them and calmly wait

To our life's close.

Let me thank you again for the kind partiality that has made me your presiding officer, and ask at your hands both your assistance and indulgence in the discharge of the duties of my office.

THE CURETTE AFTER LABOR AND ABORTION.

By J. W. LONG, M.D., of Randleman.

(Read before the Medical Society of North Carolina at Oxford, May 27th, 1890.)

Mr. President and Gentlemen:

In asking your kind attention to the use of the curette after labor and abortion, I shall not attempt to treat the subject exhaustively, but the hope is earnestly entertained that the indications and limitations for the use of the curette may be set forth in such a light as to make these remarks at least suggestive of the proper course to pursue in the conditions we are about to discuss.

That intra-uterine therapeutics have not yet crystalized into cardinal doctrines may be readily seen by reference to the medical journals and transactions of societies. Again, it is wonderful how much resistance is encountered by any new procedure looking to an improvement on the old methods of managing labor and abor tion. How often we have all seen patients and wise old grannies object to a simple vaginal wash, or even to changing a lying-inwoman's linens! Nor is this resistance confined to the laity, for doctors are too often heard to deny what they style "meddlesome midwifery." Now, I believe in conservatism, and think it the greatest safeguard to human life that we possess, but I fear in this particular department the opposition sometimes partakes of the spirit that characterized the opponents of Summelwiess.

The curette is one of the most highly prized instruments that I possess, for, besides the numerous indications for its use in the nonpuerperal state, labor and abortion are of such everyday occurrence, and each case being liable to such grave complications of hemorrhage, infection and retention of the products of conception, there is a pressing necessity for some means by which we may "become master of the situation." In the curette we have a therapeutic resource that is not only efficient when properly and judiciously used, both as to time and subject, but is convenient, easily applied and safe.

There are just three indications for its use in the days immedi

ately following delivery at term or prematurely. These are infection, hemorrhage and retained membranes.

There are other indications that might arise later, as chronic metritis, fungus growths, hemorrhage, etc., but it is not the object of this paper to discuss these.

We will first consider puerperal infection, or child-bed fever. While the puerperal woman may be the subject of almost any disease-typhoid, malaria, pneumonia, or anything else—it is the well-founded belief of a majority of medical men of to-day that the fever common to the lying-in period is, in all of its forms, an infection. No one claims for a moment that the infecting agent is always the same, or that it affects every patient alike, but, as Dr. Grandin says: "The doctrine of to-day is that all essential deviations from the normal in the puerperal state are due to infection, in one way or another, of the puerperal tract."* As a rule, the infecting germ gains access to the endometrium, and here the septic process is inaugurated. Of course, the infection is localized at first, and this is the time the infecting agent should be attacked with irrigations and the curette, and thus destroyed before it is swept into the circulation and poisons the whole system. Without going into the details of the pathology of puerperal septicemia, or dealing in scientific technicalities that would only tend to confusion, it is enough for the practical physician that he divide puerperal septicæmia into two forms:

1. That form which is etsentially a decomposition—a putrefac

tion.

In these cases a bit of retained placenta, or membrane, or bloodclot, or some tissue of low vitality, is attacked by the germs of putrefaction, and the morbid process, once set up, rapidly spreads to the contiguous intra-uterine tissues. It is probable that no germs are carried into the circulation, but the product of decomposition, which is supposed to be a chemical agent, is sucked into the veins and lymphatics and systemic intoxication (there is no other word that expresses it) is the result. These cases have no complicating cellulitis or peritonitis, but are simon-pure cases of intoxication from some poisonous agent. By way of illustrating this form of puerperal fever I cite:

*New York Medical Journal, February 16, 1890. Page 172.

SEPTICEMIA AFTER LABOR AT TERM.

Case 1.-Two years ago last spring I was summoned hastily by wire to attend a consultation in a neighboring town. The two physicians in attendance kindly met me at the depot and stated frankly that they did not know what the trouble was. As we walked to the house they gave the following history:

The patient, Mrs. G———, a young primipara, was delivered by one of the gentlemen two weeks before and had no trouble during labor nor until a week afterwards, when he was summoned and found her pulse 130, some fever and very great prostration. She had grown gradually worse during the following week. I found her in articulo mortis, pulse 156, shallow respirations, comatose. It was impossible to discover any lesion outside of the genital tract. There was no peritonitis, not even any tympany; in fact, the anterior abdominal wall had sunken in till it rested upon the spinal column and the hypogastric region resembled a basin. Bi-manual examination revealed the uterus anteverted to the most extreme degree I ever saw, so much so, in fact, that the fundus was lower than the cervix; of course there could have been no proper drainage. I told the husband and physicians that the patient was bound to die-was dying then, but I would like to prove my diagnosis of puerperal septicemia (or, more properly, sapræmia) by washing out the uterus. They readily consented, and, by means of a metal male catheter and syringe, we washed away a quantity of highly offensive putrid detritus that no doubt was the cause of the woman's death.

2. The second form of puerperal septicemia is caused by a germ, probably the round bacteria, which on reaching the interior of the uterus rapidly multiplies and is carried into the lymph circulation, where it continues to increase and forms in whatever tissues it may be conveyed depots of pus and secondary foci of infection. These are the cases where we have cellulitis, peritonitis, lymphangitis, etc.

From this it may be readily seen how local treatment by irrigation or curette would be effective in the first form, where we have to deal with simply a local putrefaction and its resulting chemical product; and in the early stage of the second form before the germs enter the circulation. In this second form, after the microbes have

passed into the lymph channels, neither irrigations nor the curette can be of much avail, and may do positive harm. But in the first, or that form resulting from the absorption of the chemical products of decomposition, it is a singular fact that, no matter how extreme the degree of putrid intoxication anywhere short of the very article of death, removal of the putrefying mass and thorough cleansing of the uterine cavity, will cause the patient to react as rapidly in many instances as a red-hot iron cools on being removed from the fire! This is a strong assertion, but cases in my own practice bear me out, and I doubt not many gentlemen present have seen just such cases, while medical literature contains numerous illustrations of this fact.

While the object of this paper is to advocate the use of the curette in puerperal septicemia and other conditions to be mentioned presently, I wish to be careful not to prove too much, for quite often this very class of cases that we are now discussing yield most brilliant results without resorting to the curette.

SEPTICEMIA AFTER LABOR AT TERM.

Case 2.-Is a striking instance of the immediate good effects of local treatment without using the curette. In November, 1886, I attended Mrs. P— * through a normal delivery. She did so well that her case was dismissed after the second or third visit. On the twelfth day after labor I was again called to see her, and found her nearly dead-tongue pointed, red and parched; skin dry, harsh and icteroid; constipation; urine scanty and highly colored; temperature 101°; pulse 120-130, with little volume and very compressible; respirations humid and shallow. There was absolutely no tympany, not any tenderness except over the fundus. The lochia was abundant and offensive. Her features had that pinched, drawn expression that indicates speedy dissolution. Bi-manual examination revealed the uterus perfectly movable, subinvoluted, boggy, and the os patulous. There was no fullness nor tenderness around the When the hand was withdrawn from the vagina it was literally dripping with pus, the most putrid I ever saw, and if I had not hastened to the door I should have vomited. Here, then, was a woman who was dying from putrid intoxication due to a suppu

uterus.

*This case was reported at the time in the Nashville Medical News.