were so weak as to be practically inert. When it is borne in mind that these are medicines regularly prescribed by physicians, and not proprietary remedies, the possibilities of serious results are obvious. Radical reform, under threats of prosecution, was agreed to by the offenders.

Athletic Overstrain and Acute Cardiac Dilation result from the excitement of college contests and there must be as many cases with permanently damaged irritable hearts as among soldiers in war. Mature adults, as a rule, are not so capable of exerting themselves to such a point. Only the youth has the nervous energy and therein is the danger. The cases of "exhaustion" among the defeated "varsity" crew are really blots upon the medical profession-the professional trainer does not know of the after-results and is less to blame. His occupation should be eliminated from all colleges, and the boys left to the more natural methods they instinctively pursue. It is time to teach boys that mere muscularity and hard manual labor are not conducive to longevity, while moderate exercise is. The desire to develop the body as a means of developing the brain, has carried us too far. It is a matter which parents expect the faculties to remedy.American Medicine.

ANNOUNCEMENTS.

A New Specialty in Medicine. Physicians who are interested in the study and legitimate practice of the physical therapeutic methods, notably electro-therapy, phototherapy, mechano-therapy, hydro-therapy, suggestion and dietetics, are invited to join the American Physiotherapeutic Association. Address the secretary, Dr. Otto Juettner, No. 8 W. Ninth St., Cincinnati, Ohio.

The officers for the ensuing year are: President, Dr. H. H. Roberts, Lexington, Ky.; Secretary, Dr. Otto Juettner, Cincinnati, Ohio; Treasurer, Dr. Geo. H. Grant, Richmond, Ind.

International Congress of Dermatology. The Sixth International Dermatological Congress will convene by special invitation in the city of New York on the 9th of September of the current year, and will remain in session for one week. The first congress of this kind met in Paris in 1889, and since that time at intervals of about three years it has been held in Vienna, London, Paris and Berlin. At the Berlin meeting in 1904 New York was selected as the meeting place for 1907, and Dr. James C. White was elected president of the congress.

The Organization Committee extends an invitation to all to attend the congress and take an active part in its proceedings.

The themes selected for formal consideration are:

I. The Etiological Relationship of Organisms Found in the Skin in Exanthemata. II. Trop ical Diseases of the Skin. III. A. The Possibility of Immunization Against Syphilis. B.

The Present Status of Our Knowledge of the Parasitology of Syphilis.

A full program will be sent in June, 1907, to all who accept membership, or who signify their intention to attend the congress. Also details concerning transportation, accommodations, registration, etc. John A. Fordyce, M. D., Secretary-General, 80 West 40th Street, New York City.

Reviews

Surgery: Its Principles and Practice. In five volumes. Edited By 66 eminent surgeons. by W. W. Keen, M. D., LL. D., Hon. F. R. C. S., Eng. and Edin., Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical College, Phila. Vol. I: Octavo of 983 pages, with 261 text-illustrations and 17 colored plates. Philadelphia and London. W. B. Saunders Company, 1906.

A work in which are collected and preserved in permanent and accessible form the ripened experiences and matured judgment of one eminent as a practitioner and teacher is sure to be glady welcomed by the profession. The editor's long, busy and conspicuously successful career eminently qualifies him for this selfimposed task. The completed work, which he now lays upon the altar of his profession, in discharge of the obligation that rests upon him, as upon all of us, to render unto it the best fruits of our lives, will not only shed additional honor upon it and upon himself, but will for a long time to come be a most helpful factor in the equipment of those who go forth to strive in the field where he has achieved such merited success. After all, it is the ripened fruits that the profession most desires and approves, and it is better content to abide the time of the ripening than the young, the immature and the ambitious sometimes give it credit for being. The corps of collaborators which the editor has associated with himself has been chosen with full knowledge of the qualifications required and possessed in each individual instance. Vol. I, which has lately been issued, gives ample evidence of the thoroughness with which their work has been done. As to its mechanical features, no criticism could be offered. The paper, binding, typography and illustrations are models for the best work of the book-maker's art. This first volume naturally deals with the fundamental principles of surgery; the physiology and pathology of surgical processes, and the consideration of general surgical affections; destructive, reparative, and infective processes, etc. Of its twenty-two chapters, those on surgical physiology; and wounds and contusions, by Crile, embodying his investigations into the nature and treatment of shock; examination of the blood, by Dr. Costa; infection and immunity, by Hektoen; tumors, by Bland-Sutton; diseases caused by special infections; and diseases derived directly from animals, insects and reptiles, by Frazier; might be especially named. At the beginning of the work is an interesting chapter on the History of Surgery, with condensed

sketches of many who in ancient and later times have contributed conspicuously to its progress. The naming of these, however, must not be taken to indicate that any of the others fall short of the first order of excellence. Editor, collaborators, and publishers are to be heartily complimented on their work thus far, and the appearance of the subsequent volumes will be awaited with eager interest.-W.

The Practice of Gynecology.-New (3rd) edition, thoroughly revised. A Text-Book on the Practice of Gynecology. For practitioners and students. By W. Easterly Ashton, M. D., LL. D., Professor of Gynecology in the MedicoChirurgical College of Philadelphia. Third edition, thoroughly revised. Octavo of 1096 pages, with 1057 original line drawings. Philadelphia and London: W. B. Saunders Company, 1906.

When this work first appeared it was at once recognized as having peculiar merit. There was in it nothing hazy or uncertain. No space was wasted in the discussion of moot points, but the author's own opinions and methods were clearly set forth, these being the deductions of careful research and large experience. That a third edition should be demanded so soon is abundant evidence of unusual merit, and this merit we believe to consist in the careful detail with.which every topic is treated. Methods of treatment and operations are most fully and accurately described and all needed instruments pictured so that there is little excuse for one who fails to understand. writer's library contains more than twenty volumes on women's diseases, but he does not hesitate to say that for the general practitioner's use Ashton's work is by far the most valuable, and perhaps the only work on the subject that he needs.-J.

The

A Practical Treatise on Materia Medica and Therapeutics, With Especial Reference to the Clinical Application of Drugs.-By John V. Shoemaker, D.D., L.L.D., Professor of Materia Medica, Pharmacology, Therapeutics, and Clinical Professor of Diseases of the Skin in the Medico-Chirurgical College of Philadelphia; Physician to the Medico-Chirurgical Hospital; Member of the American Medical Association and the British Medical Association; Fellow of the Medical Society of London, etc., etc. Sixth Edition. Thoroughly Revised. (In conformity with Latest Revised U. S. Pharmacopeia, 1905.) Royal Octavo, 1244 Pages. Extra Cloth. F. A. Davis Company, Publishers, 1914-16 Cherry Street, Philadelphia, Pa.

A medical work that has been before the profession for nearly twenty years, and of which six editions have been called for, has demonstrated its right to live. "Shoemaker" has long been one of the few very widely used works on Materia Medica. This edition shows many evidences of careful revision. An entire new section of seventy pages has been added, containing much very badly needed information on incompatibles, prescription-writing, methods of administration, and changes in strength of drugs, also poisons and antidotes, classification

of remedies and the general principles of therapeutics.

Part II follows with the full consideration of drugs in alphabetical order and their therapeutic application. We offer a criticism here that will apply to almost all works of this kind, viz., very many of the drugs treated of might be omitted without loss to the reader, who wcric thus gain time for the closer study of really valuable ones.

Fart III treats quite fully and satisfactorily on "Non-Pharmaceutical Remedies and Expedients," these embodying electricity, massage, vibro., pneumo- and hydrotherapy and psychotherapy, and a consideration of suggestive therapeutics, is also presented. We know of no book in which is more fully considered the latest things in therapeutics. While the work is rather too full for the student, it is a most valuable work for the progressive practitioner's library.-J.

Saunders' Pocket Medical Formulary. New (Sh) Edition, Adapted to the 1905 Pharmacopeia. By William M. Powell, M.D., author of "Essentials of Disease of Children"; member of Philadelphia Pathologic Society. Containing 1831 formulas from the best known authorities. With an appendix containing Posologic Tables, Formulas, and Doses for Hypodermic Medication, Poisons and their Antidotes, Diameters of the Female Pelvis and Fetal Head, Obstetric Table, Diet-lists, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, etc., etc. Eighth Edition, Adapted to the New (1905) Pharmacopeia. Philadelphia and London: W. B. Saunders Company, 1906, in flexible morocco, with side index, wallet and flap.

Little need be added to the above very full description of a book which is certainly one of the best of its kind. We do not believe such works should be used too freely, for they may lead to routine work. Occasionally, when a physician has exhausted his resources, especially when far in the country, away from library and professional aid,, invaluable help may be had from such a book as this, and to the country practitioner, especially, it will often prove "a friend in need."-J.

Diabetes Mellitus; Its Pathological Chemistry and Treatment.. Lectures delivered in the University and Bellevue Hospital Medical College, N. Y. Herter Lecture Foundation. By Professor Dr. Carl von Noorden, Physiclan-in-Chief to the City Hospital, Frankforta-Main. E. B. Treat & Co., Publishers, N. Y. Van Noorden's studies of the disorders of metabolism and nutrition, of which this little work forms a part, have added much to our knowledge, and improved our treatment of these disorders. No article is written on these subjects that does not contain quotations from and reference to Von N.'s writings. This book consists of lectures delivered by the learned professor in the N. Y. hospitals, and no single book on the subject contains so much that is new and valuable touching the pathology and management of diabetes mellitus.-J.

Original Articles.

THE UTERINE CURETTE.

Chester Ogden, M.D., Clarksburg, W.Va.

(Read at Annual Meeting State Medical Asso. June, 1906.)

Surely since the day Eve, with her husband Adam, was driven from the Garden of Eden, before Sarah in her old age conceived and bore the promised son Isaac, long before Moses was laid away in the bulrushes to be saved as the leader of his people, and ere the news of the Child Jesus burst on the hill-tops at Bethlehem, has woman's womb been the source of pain. There is no doubt that woman in every age of the world, and among all the tribes of men, has sorrowed because of her womb. It is not, however, until the dawn of modern civilization, with its rapid and perverted ways of living, that so much uterine trouble has arisen, demanding so much consideration from the medical profession. Certainly it was not till within a century ago, that the instrument which gives title to my paper was introduced to the profes

sion.

Speaking of the uterine curette, I speak in the rhetorical sense of the instrument for the operation for which it is used. I am of the opinion that this instrument, though intended for good, has become in its application, among surgical instruments, the most misused and abused. It is to be considered as the most potent factor in the causation of actual suffering, certain dis

Subscription Price $1.00 per Year. Single Copies 20 Cents

appointment, and probable death, of any instrument, heretofore considered harmless, now used by the gynecologist and obstetrician. I feel reasonably certain that I but speak the sentiments of many physicians when I say that the sharp uterine curette, the operation and purpose for which it is used, bring us more unfavorable and disappointing results than are found in any other department of our work.

It is not my purpose to assail the user of this instrument, or criticize any one for its promiscuous use more than myself, for I freely admit my mistakes in its use, as I fear too many of my professional brothers are making to-day, and I come to you with the hope that I may in some degree prevent the same mistakes in the hands of others.

The uterine curette is by choice the instrument the would-be surgeon selects for his first important operation, that he may attain surgical prominence, thus impressing the laity of his having performed some wonderful piece of surgery, and laying claim to large fees for operative procedure and surgical interference that should have been left unperformed.

The profession generally has been too prone to resort to the curette as a relief from every abnormal condition of the uterus, expecting in it the means of both establishing a diagnosis and effecting a cure. It has been used for the mildest endometritis as well as for the most severe pelvic disease, for hemorrhage, sterility, leucorrhea, salpingitis, diseased ovaries, and for nearly every pelvic disease peculiar to womankind. With some there is no disease so grave as to bar its use, and no path

ological condition so mild as to escape its application.

In speaking of the curette, I shall mention both the sharp and the dull, limiting the extent of their use, and widening the extent of their abuse. Distinguishing between the two, we understand that curettage is done only with the sharp curette. The process of removing placental debris and blood clots, as done with the blunt loop curette, is no more a curettage than is the use of the finger for the same purpose. Indications and Contraindications for the Curette: When we have a pathological condition within the uterus, presenting an abnormal endometrium, when the previous history of the case, and the local conditions point to the probability of carcinoma, sarcoma, polypoid growths, cysts, etc., we may with propriety use the sharp curette to remove portions of intra-uterine tissue for diagnostic purposes.

Too often we are led to believe by destroying a diseased endometrium a more healthy normal one will be formed. This result we have all led ourselves to believe can be reached, and in our believing, promise our patients that by scraping the womb we can cure chronic catarrhal endometritis and all inflammatory conditions of the uterus. To accomplish such a result, it is plain that all old diseased lining must be removed, and not a particle remain, and anyone who has ever used this instrument knows, that no one with a small sharp curette, simply by scraping around in an unknown cavity, can remove every particle of diseased tissue within any more than he can locate every article in a darkened room with which he is not familiar.

Further, granting that it were possible to touch every particle of endometrium, if the result of curettage is observed in the extirpated uterus, we will find the utter impossibility of removing the endometrium by the curette, even by the most vigorous application, saying nothing as to amount left unremoved in the unextirpated uterus-on which a curettage has been blindly done.

All over the land, in hospital and private practice, in this day of advanced thought and practical application, we find inveterate "womb scrapers," men who really believe that curettage is the panacea for every woman's ills, and will bring health and happiness to all affected with pelvic disease, as well as to those who resort to it as a

means of doing an operation that they may have fame abroad as surgeons.

In my opinion, there is no operative procedure that requires more skill, a more perfect knowledge of pathology, and a more delicate experience with instruments, than uterine curettage. In my own observation and experience, I have found that the sharp curette, as used in the majority of cases, has done more harm than good, and that the majority of patients have been disappointed in obtaining the relief so much desired. The woman who undergoes a uterine curettage of the more important type has to undergo the same dangers from anesthesia, sepsis and loss of time by sickness as those who submit to operative procedures, in which the true condition is more apparent, and in which one can with reasonable certainty promise relief. Thus, in this uncertain and mistaken procedure, the patient loses faith in operator, is disappointed in operation, and as a result decries all surgical interference when by chance some pathological condition arises in which operative interference might effect a cure.

Thousands of women today are suffering from chronic endometritis, peritoneal inflammations and other sequelae as a result of the curette, and are going about as specimens of suffering humanity, refusing proper medical and surgical treatment simply because they have been disappointed in the hope of better health by the promises and mistakes of the uterine scraper.

In rare cases of chronic endometritis in which there is a marked hypertrophy, a gross thickening of the uterine wall, the curette may be permitted under the most aseptic precautions, and when employed by the most experienced gynecologist.

Contraindications for the use of the Curette: Some of these are (a) lack of experience of operator in uterine surgery; (b) uncertain knowledge of the pathological conditions; (c) fixed conditions of the uterus from adhesions resulting from exudates from inflamed peritoneum; (d) the puerperal state with retained products of conception after abortion or miscarriage, in the attempt to remove which not only is damage done to the soft spongy uterus, producing probable puncture of that organ, but distributing sepsis by raking in, as it were, seeds into fertile ground, and starting thrombi in the veins at the placental

site, which are carried into the circulation as emboli.

We frequently note deaths from abscess resulting from an embolus started by the curette. In puerperal cases when there are retained products of conception, I employ one of the more recent sponge holders, with which you are all familiar. This instrument being smooth, round, and blunt, produces no traumatism to the uterine wall, and acting as forceps enables one to safely explore and pluck away even the smallest particles of debris.

If the uterus is well dilated or can be easily dilated, I know of no better evacuant than the first finger. The smallest particles may escape the curette, but the well trained and ever sensitive finger will detect every particle, and whenever possible its use is indicated. In other cases, when it is not possible to introduce the finger, I employ either the sponge holder, as mentioned, or the small blunt loop curette, sometimes placing over it a piece of rough meshed sterile gauze, which both by absorption and friction catches up and brings away the smallest particles of debris.

Frequently we hear of physicians using the sharp curette as a means of curing sterility, when little consideration is given to the real cause of the woman's inability to be a mother, whether her ovaries are functionating properly, her tubes patulous, coitus properly consummated, or whether there be a probable impotency of the husband. In cases where examination reveals nothing abnormal, uterus not particularly enlarged or contracted, adnexa normal, husband potent, when sterility has existed a long time, by simply dilating the cervix and introducing the uterine sound into the uterus, with a little attention to the patient's blood pressure and with daily hot boric acid douches, sterility will in the majority of cases be removed. The importance of this simple procedure was pointed out long years ago by Sims, and Goffe, of New York, lays special stress on the simple dilation of the cervix, followed by the systematic douche.

The use of the curette in sterility is contraindicated, because sterility does not, as a rule, exist in the uterine body, being dependent largely on the condition of the cervix, tubes, and ovaries, and no possible good can come from the use of the sharp instrument on the body of the uterus, to

ward establishing fertility; while on the other hand, there is great danger of traumatism to the organ, and a probable infection resulting in a cellulitis, contracting the tissue, and organized exudates fixing the uterus and appendages.

There are certain complex cases in which there is continual hemorrhage, following abortion and otherwise, when patient complains of pain; in such cases, I oppose the uterine curette, but prefer to first dilate the cervix sufficiently to admit the finger or sponge holder forceps, when frequently products of conception or polypi are found, which are the cause of the pain and hemorrhage. These may adhere to the uterine wall so firmly, that in some cases the curette will be unable to dislodge them. If the uterus is well dilated, the offending particles may be easily removed by the palpating finger or by the curette guided by the finger in its introduction and application.

If, on the other hand, there be in the uterus neoplasms, such as sarcomata, this palpation will enable one to detect them. The question may arise as to how to dilate the cervix sufficiently to admit the finger in cases of the so-called rigid os. In cases where anesthesia is not given, Duhrssen of Berlin advises our return to the laminaria tent a method almost discarded in this country, although it was originated in America. He advises its use, and declares the tents act most safely and satisfactorily, and that the once unpleasant consequence of sepsis can, at present, be avoided. Tents of this kind can safely be sterilized by keeping them eight days in 10% sablimatealcohol solution, and if our conscience be not yet satisfied, dip them in boiling water one minute just before using.

Twenty-four hours is enough to dilate the uterus by this method, sufficiently to admit the finger, and if this method be used the patient is saved fissures and tears in the musculature of the cervix.

If it should be the misfortune to find one of these rare cases in which the cervix is so rigid that such a procedure will not suffice, I am constrained to believe the most satisfactory method is the one recently used and advised by the German gynecologists, of splitting the cervix anteriorly, that is, doing a Caesarian section on a small scale.

In septic inflammations of the endometrium, the curette should never be used, as