and hæmorrhage causing alarm, assistance was sent for. When I arrived the attentant was not there, but I could easily gather what had been intended. Chloroformed, the tip of what must be a tent could be felt by pressure on the cervix below, I did not press on the fundus, as in a Hoenning, for theoretically there must be danger of the tent's edge cutting the uterine walls, possibly through and through. With

FIG. 3.-A. Oval sac from Case II., serotinal aspect, tenth week.

B. Laminaria tent, cause of abortion, had slipped up so as to be covered by

the cervix; attendant alarmed, dropped the case.

C. Decidual and oval cast from Case III., of seven to eight weeks. Cause of abortion not ascertained.

the finger tip the cervix was easily opened, for the canal was well dilated and the tent removed by means of a dressing forceps. Thereafter the partially loosened oval cast was completely shelled off and expressed, followed by a carbolic uterine douche; vaginal douches subsequently. Fourth day after, patient got up and about.

Case III.—This is a decidual cast, partially loose when I was called; with finger completed the loosening; spontaneous delivery.

Aside from the arguments against the finger that it is unsurgical and septic, and which experience and time have shown "not proven,"

it is claimed (1) that the tip of the finger cannot reach the fundus and remove all the secundines; (2) curage, it is claimed, is more painful than curettage. Ruling out the anatomically or physically defective hand and finger of an operator, I have found in discussion that where this first objection has held that the finger cannot reach the fundus, the

FIG. 4.-A. Oval sac from Case II., laid open to show.

1. Fetus.

2. Cord.

3. Intestine, hernial, through umbilical opening.

4. Placenta, amniotic side.

5. Placenta, serotinal side.

B. Laminaria tent causing abortion.

B. Laminaria tent, original size.

C. Decidual and oval cast from Case III., of seven to eight weeks, laid open and shows (1) amorphous mass representing remnant of foetal development.

index finger had been made use of. Now, I admit and have so maintained, that the index finger is often too short of reach, and unreliable. I tried the index finger in my first case, and because it failed me I changed to my middle finger, for the middle finger is longer, stronger, and swivels better. I introduce my half hand into the vagina and but one finger, the middle finger, into the uterine cavity, receiving the uterus as a ballooned finger tip over the middle finger, and between

the index finger against the anterior lip before, and the fourth and little fingers against the posterior lip behind. Thus the uterus swivels upon the middle finger as an atlas, controlled and inclined forward or backward by the fingers encircling the cervix without. Abdominal pressure is made as necessary with the other hand.

I have yet to meet a uterus whose fundus I cannot reach and whose cavity I have been compelled to curage a second time for retention, or where a placental polyp has subsequently developed. This the index finger cannot accomplish so well, as a rule; the middle finger can.

FIG. 5.-Illustration showing middle finger method of digital curage.

The second objection that curage is more painful than curettage. It should not be so especially if chloroform be given. Even were it so, the security of knowing that the cavity is clear and that all danger has been removed, amply repays for the slight transient discomfort produced by the introduction of the half hand into the vagina. It is only a clumsy operator who is brutal, nor is such awkwardness a feature of digital manipulation alone, for a clumsily-handled instrument is far more efficacious of inflicting pain than is the finger. Moreover, I have yet to meet the patient who would not gladly lend to tons of sweetscented hyperbole rather than one iota towards an ounce of death certificates.

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EDITORIAL.

GYNECOLOGICAL OPERATIONS UPON THE INSANE.

Another report of the results of gynæcological operations upon the insane of the London (Canada) Asylum is given by Dr. R. M. Bucke in the Medical News. Up to the present time 256 women have been examined and in 219 of these structural disease of the uterus, ovaries or adnexa has been found. Of these cases 200 have been operated upon, the sum total of different operations done being 362. Four deaths have resulted but in almost all the other cases there has been improvement or restoration of bodily health. As to the mental effect, 83 women have recovered from their insanity and 45 others have markedly improved, while in 68 there has been, as yet, no change. Of course some cases recently operated on may improve or recover and some that have improved may eventually recover.

These figures are the more remarkable when we consider the results of other operations upon the mental condition of these patients. Out of 63 cases operated upon for extra-gynæcological lesions (mostly herniæ or new growths) there was but one mental recovery. Classify

ing the 196 gynæcological cases, we find that by far the best mental results were attained in those cases in which diseased conditions of the tubes and ovaries were rectified, next those in whom disease of the uterus, body or cervix was cured or malpositions of the uterus or adnexa corrected, while the mental condition was less frequently influenced by the removal of uterine tumors and much less by the repair of torn perinæa, fistulæ, etc. From these observations we may ascribe to these various lesions corresponding degrees of influence in the production of mental disease. The general statistics of the asylum, moreover, show the influence of this new factor in treatment; the average recovery rate, including cases improved, based upon the admissions, was in the female halls during the four years preceding the institution of this work 35 per cent., and in the four years during which this work has been done 51 per cent.; while in the male halls there was very slight gain during the second period over the first.

The report is a very frank and straightforward brief record of this interesting work. On reading it, one is impressed with the idea that these patients are not regarded as material for experiment but as subjects to be benefited first physically, afterwards mentally if may be, by operation. In no case is the operation done for insanity. Physically the patients are regarded precisely as if they were sane and, if found to be affected, are treated in the same way and to the same end, i.e., the relief of physical suffering, whether it is thought that the operation will affect their mental condition or not. Sometimes it is known that it will not; at other times it is regarded as the first step toward restoration to general health. But the operation is done in every case on account of physical indications; if an improved mental condition result, so much the better.

These facts, it seems to us, are a sufficient answer to any who may have felt that the work might partake somewhat of the character of experiment upon irresponsible subjects. We should say that in the average insane asylum, where the staff would be quite likely to have comparatively little practical surgical knowledge, the tendency would be to neglect surgical indications rather than to operate indiscriminately and experimentally. Certain important points are neglected in the report the kind and duration of the insanity thus favorably affected and the prognosis without operation; moreover statistics are deceptive things; but, making all due allowances, it appears that very excellent results have been attained, which it would be well for those to keep in mind who have to do with cases of insanity.

A. D. C.