THE CURETTE 
AS A 
DIAGNOSTIC AND THERAPEUTIC AGENT 
IN 
Gynecology and Obstetrics. 
By B. BERNARD BROWNE, M. D., 
Professor of 
Diseases of Women in the Woman's Med- 
ical College of Baltimore, etc, 
Reprint 
FROM TRANSACTIONS OF 
iVU’bical anb Chirurgical jTacultjn, 
of the State of Maryland. 
1886. STEAM PRESS OF 
GUGQENHEIMER, WEIL & CO. 
BALTIMORE. [Reprint from “Transactions of the Medical and Chirurgical Faculty of 
Maryland" for 1886.] 
REPORT OF THE SECTION ON OBSTETRICS AND 
GYNEC0E0GY. 
THE CURETTE AS A DIAGNOSTIC AND THERAPEUTIC 
AGENT IN GYNECOLOGY AND OBSTETRICS. 
By B. Bernard Browne, M. D., 
Professor of Diseases of Women in the Woman’s Medical College of Bal- 
timore, etc. 
The members of this Section, in deviating from the well-trodden 
path of making a full report of the progress in obstetrics and 
gynecology during the past year, do it not because sufficient 
material for such report is wanting, for the advances in abdomi- 
nal surgery alone would be ample to occupy all the time allotted 
to this Section. 
The Section will report as follows: 
1. “The Curette as a Diagnostic and Therapeutic Agent in 
Gynecology and Obstetrics,” by the Chairman. 
2. “ A Temporary Clamp, for Use in Ovariotomy, Oophorectomy 
and Tait’s Operation,” by Dr. Robert T. Wilson. 
3. “Puerperal Eclampsia,” by l)r. (t. W. Miltenberger. 
4. “A Case of Labor complicated with Fibroid,” by Dr. D. W. 
Cathell. 
Believing that the curette has not yet reached the full measure 
of its usefulness, I offer no other excuse for making it the subject 
of my portion of this report. 
As is well known, Recamier used his sharp curettd with great 
success during the early part of the present century, but he did 
not call the attention of the profession to it until 1850. His 
pupil, Robert, however had announced some of Recamier’s views 
and results as early as 1840. Recamier found that the cauteriza- 
tion of the uterine cavity for the destruction of fungoid growths 2 
B. BERNARD BROWNE, M. D. 
and small polypi was ineffectual, and that scraping the cavity 
with the sharp curette gave much better results. For a time 
these operations were very successful in the hands of Recam icr 
and his followers, hut later on grave complications—peritonitis, 
phlebitis and septicemia frequently occurred—and the operation 
met with such decided opposition that it was altogether aban- 
doned. Of late years, however, the dangerous, sharp curette of 
Recamier has been replaced by different forms of the dull curette, 
most of which are modifications of Thomas’ dull wire curette, 
which was introduced about 1870. Previous to that, however, 
the sharp steel curette of Sims had been used to a certain extent 
within the cavity of the uterus, but its chief field of usefulness at 
present is for the removal of glandular diseases of the cervical 
canal, and for this purpose there is no instrument superior to it. 
As a diagnostic agent in ascertaining the desired condition of 
the uterine cavity, in the various chronic diseases of this organ, 
the dull wire curette has a vast field of usefulness. Its introduc- 
tion is attended by a little more difficulty than the Simpson’s 
sound. A slight amount of dilation with a dilator is necessary in 
order to allow its easy passage and prevent injury to the cervical 
tissues; by gently passing the curette over the interior of the 
cavity of the uterus, a very perfect knowledge of its size and con- 
dition may be obtained. The roughness or smoothness of its sur- 
face at particular parts would indicate respectively the locality of 
its diseased or healthy portion; also the scraping off and removal 
of a small portion of the diseased structure, would give a positive 
knowledge of the character of the disease. 
In menorrhagia, metrorrhagia, leucorrhoea and subinvolution, 
the symptoms which indicate the use of the curette are so pro- 
nounced that its diagnostic and therapeutic use are simultaneous. 
In these cases a more complete dilation, under the influence of an 
anaesthetic, should precede the introduction of the curette. The 
dilatation insures free drainage, besides, it relaxes the constric- 
tion which generally exists at the internal os, even where the 
external os is perfectly putulous. This constriction, which exists 
in nearly all cases of chronic hyperplasia of the uterus, appears to 
keep up a passive congestion of the organ, by interfering with the 
normal circulation through the vessels at the vaginal juncture. 
By dilatation, the circular fibres of the cervix are also relaxed, 
and a process of involution afterward goes on in the uterus. 3 
SECTIOX OX OBSTETRICS AXI) GYXECOLOGY. 
Antiseptic precautions should always be observed in using the 
curette, and if any pain should occur, a suppository of opium or 
other anodyne should be used. 
Contra-indications to the nse of the curette, are cellulitis, 
pain and tenderness over the uterus, or pelvic inflammation. 
The whole surface of the uterus should he gently scraped over, 
and all endometrial growths removed, and any roughened or uneven 
surface should be smoothed off. Formerly, I always used an appli- 
cation of Churchill’s tincture of iodine to the cavity after using 
the curette, but now 1 make no intra-uterine application, but 
allow drainage, and apply an absorbent antiseptic pad to the 
vulva. Endometrial growths* are always confined to the cavity 
of the uterus proper, stopping at the os internum, below which 
commences the region of enlarged nabothian follicles and mucus 
polypi in the cervix. The difference consists in the large masses 
of dilated glands found in the last named affection, which are 
absent in the former. 
Polypi of the uterus are distinguished from the fact, that they 
are generally confined to a small part of the endometrium ; while 
the chronic hyperplastic endometritis extends over a large surface. 
In nearly all cases of chronic inflammation and hypertrophy of 
the nabothian follicles, or utricular glands of the cervix (of which 
according to Tyler Smith, there are at least 10,000 in the cervical 
canal alone), a thick tenacious plug of mucus hangs from the cer- 
vix which it is often difficult to remove. 
In these cases, where the secretion is albuminous and persistent, 
and remains unchanged in spite of the use of all the stronger 
caustics, the Sims’ curette, with sharp cutting edge, will effectu- 
ally remove the hypertrophied glands down to healthy tissue, and 
will generally effect a permanent cure; for this purpose it is 
often necessary to dilate the cervix with tents before the curette 
is used. 
In nearly all cases of supposed return of the menses occurring 
after the menopause and continuing for years, a pathological con- 
dition of the uterus exists, and, what has been related as a won- 
derful prolongation of a physiological process, is in fact a diseased 
condition of the endometrium, which is readily removed by the 
curette. i 
*“On the Use of the Curette as a Therapeutic Agent in Gynecological Practice.” 
—The Obstetric Gazette, Vol. V, page 452. 4 
n. BERNARD BROWN®, M. D. 
There is a class of eases we meet with, giving a previous history 
of abortion which may have occurred several years before ; these 
eases present all the symptoms of chronic uterine disease, such 
as menorrhagia, leucorrhcea, back-ache, etc. , they are generally 
improved by any intelligent plan of treatment; tonics benefit them 
for a while, and local treatment, such as vaginal douches, appli- 
cations of iodine, etc., improve them very much, but they soon 
relapse and are as bad as before ; tin’s condition is frequently, I 
believe, a remote result of partial retention of the placenta. In 
these cases, if the dull wire curette be used, it will be found that 
the former placental site is studded over with numerous little 
cysts, from the size of a shot to that of a pea, which, when removed 
by the curette, will float upon water and have the appearance of 
small air bubbles. 
In laceration of the cervix with profuse leucorrhcea, the use of 
the curette is attended by more benefit than intra-uterine appli- 
cations, as' a preparatory treatment previous to the operation for 
restoring the cervix. 
For removing the placenta after an abortion, the finger is the 
most efficient curette; we may render the uterine cavity completely 
accessible to the exploring finger by the bi-manual method, but 
still better by seizing the anterior lip with the double tenaculum- 
forceps ; one of the blades grasps the vaginal aspect of the front 
wall of the cervix as high up as the roof of the vagina, the other 
at a corresponding level within the cervical canal. The uterus is 
capable of being pulled considerably down without any injury to 
its ligaments or laceration. It may be pulled down with the 
right hand and kept fixed with it, while one or more fingers of the 
left pass into the cavity and explore and evacuate it. The cavity 
of the uterus is thus brought within full reach of the fingers, and 
we can in all those cases of imperfect delivery in the early months 
control the emptying of the cavity from fundus to os. The mani- 
pulations necessary to secure a satisfactory result cause some 
suffering, though not to a great degree, which we can always save 
the patient by bringing her under the influence of an anaesthetic. 
THE FINGERS OR HAND AS A CURETTE AFTER LABOR. 
We are told by many of the obstetrical works that meddlesome 
midwifery is a dangerous thing, that we should leave everything 
to nature, that any handling or manipulation about the uterus at SECTION ON OBSTETRICS AND GYNECOLOGY. 
5 
this time should he avoided. But, when secondary hemorrhago 
comes on, or peritonitis, or septicemia or mammary abscess occur, 
or any of the diseases to which the puerperal woman is liable, the 
thought at once presents itself, “ could it be possible that any 
portion of the placenta or any clots were left behind in the uterus 
to cause this trouble?” If we can answer this question in the 
negative with truthful assurance, we are at once relieved of a 
weight of anxiety, perplexity and doubt. 
Examining the placenta after its delivery can give us no truth- 
ful or reliable information, on the contrary, it is calculated to lead 
one into error, for there may be a placenta succenturiata and 
one lobe of it left behind in the uterus. Such an accidental or 
supernumary placenta may very easily remain attached after the 
main body, which is complete in itself, has been removed, or a 
large portion of one may be left behind, and the most careful 
examination of what has been removed may fail to inform us 
whether or not any still remains. 
But if the placenta has been expelled by Crede's method, and 
while one hand still grasps the contracting organ, two fingers of 
the other hand, used as a curette, are introduced into the uterus, 
and while compression is still continued externally, the inferior of 
the cavity is explored and every clot removed, wre find by this 
means that much firmer contractions are secured, hemorrhage is 
not likely to occur as it is, even when a few clots remain; the 
lochial discharge ceases much sooner, and involution of the uterus 
goes on more rapidly. Erosions and ulcerations of the cervix are 
not liable to occur, as there is no foetid and decomposing lochial 
discharge to bathe these parts ; if there is a laceration of the cervix 
or partial laceration of the perineum, they will generally heal with- 
out trouble, and subinvolution of the vagina, one of the most 
frequent causes of prolapsus, is not liable to occur. 
Dr. Fordyce Barker, in his well known work on the “Puerperal 
Diseases,” makes the following statement: “It is far from the 
truth to say that partial retention of the placenta always arises 
from the neglect or ignorance of the medical attendant, for this 
casualty has occurred in the hands of some of the ablest and most 
eminent obstetricians, who have reported numerous fatal cases of 
hemorrhage from this cause. But I cannot impress upon you too 
strongly, in all cases where the artificial removal of the placenta 
is required, to exercise the greatest care to remove the whole of it, 6 
B. BEBNABT) BBOWKE, M. I). 
if this can be accomplished. In some cases of very close and 
intimate morbid adhesions it may not be possible to accomplish 
this. But this I will say in unqualified, terms, that every physi- 
cian should know whether or not he has left a portion of the 
placenta behind, and he is justly censurable when he is ignorant 
on this point.” 
If we carefully analyze all the cases of peritonitis, septicemia 
and hemorrhage occurring after labor, we will find a large majority 
of them caused by fragments of placenta and blood clots remain- 
ing in the uterus. The antiseptic fingers or even hand cannot 
cause any injurious effect. 
Dr. H. P. C. Wilson has related a very interesting case of post- 
partum hemorrhage, in which after the failure of all the usual 
means for its arrest, he introduced his hand into the cavity of the 
uterus, and raked thoroughly the placental site with the finger 
nails—this produced a prompt arrest of the hemorrhage. 
In conclusion I would state— 
1. That the curette is an important diagnostic agent in all 
obscure affections of the uterus. 
2. That its use is less painful and less likely to set up cellu- 
litis than the ordinary caustic and alterative applications. 
3. That it is more efficient for the removal of endometrical 
growth than any other agent. 
4. That after abortions its proper use will prevent hemorrhage 
and septicemia. 
5. That after labor the antiseptic fingers or hand, used as a 
curette for the complete evacuation of the uterus, will lessen the 
dangers attending the puerperal women, will prevent foetid lochial 
discharges and hasten the period of involution.