A system of practical medicine. By American authors. Vol. 4

by Unknown

DISEASES OF THE PARENCHYMA OF THE UTERUS; METRITIS AND ENDOMETRITIS.

BY W. W. JAGGARD, A.M., M.D.

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Acute Metritis.

The occurrence of an acute inflammation of the parenchyma of the non-gravid uterus has been denied by many systematic writers. Wenzel¹ says the condition is a figment of the imagination; Duparcque is sceptical; Klob² up to 1864 had never seen a case in which a positive diagnosis was possible. Emmet³ writes in the last edition of his valuable book, "Inflammation of the uterine body never occurs except after parturition."

¹ Krankheiten des Uterus, p. 42.

² Pathol. Anatomie der Weibl. Sexualorgane.

³ Gynæcology, 1884, p. 31.

Comparatively recent investigations, however, have established the fact of occurrence beyond doubt or question. While a relatively uncommon condition, many facts with reference to its causation, pathological anatomy, and clinical course are definitely known.

ETIOLOGY.—Disturbances in connection with menstruation play a rôle of great importance in the production of acute inflammation of the uterine parenchyma. The rapid cooling off of extensive areas of the skin surface, as in wetting the feet in cold water, severe exertion, or the cold-water vaginal douche, may transform the normal menstrual congestion into an acute inflammation. The retention of menstrual blood within the uterine cavity, the result of organic stenoses, flexions, or tumors, occasionally gives origin to acute septic metritis. The inflammatory process frequently extends from the endometrium to the muscular substance. Gonorrhoeal endometritis is of chief clinical significance in this connection. Duparcque's observations, confirmed in 1872 by Noeggerath, have recently attracted a great deal of attention. Säuger's statement at Magdeburg, that one-ninth of all gynæcological cases are of gonorrhoeal origin, created some surprise at the time. In the light of the recent investigations of Schroeder, Bumm,⁴ Lomer,⁵ Oppenheimer,⁶ and others, it is not considered an exaggeration, although it is still unsettled whether or no the gonococcus of Neisser is the agent of infection.

⁴ Arch. f. Gyn., xxiii. 3.

⁵ Deutsch. Med. Wochenschrift, 22d Oct., 1885.

⁶ Arch. f. Gyn., xxv. 1.

Under the heading of traumatism a great number and variety of etiological factors are included. Operations on the cervix, curetting the uterine cavity, and other minor gynæcological procedures, in the absence of careful antisepsis, may cause traumatic inflammation in the vicinity of the wound, which may involve the entire organ. An ill-fitting pessary, especially the intra-uterine stem, cauterization of the cervix or endometrium with the solid stick of nitrate of silver, intra-uterine injections, the careless passage of the sound, inordinate sexual indulgence,—are all potential causes. Bloeschke⁷ relates the history of a case in which a piece of straw penetrated the cervix of a peasant-woman working in the fields. An acute metritis was the result.

⁷ Säxinger, Prager Vierteljahrschrift, 1866, i. p. 130.

Finally, acute inflammations of the muscularis may be lighted up in the vicinity of new growths, as in the case of carcinoma of the cervix or mural fibroids. Such inflammations, however, as remarked by Schroeder, possess only a secondary significance.

PATHOLOGICAL ANATOMY.—The uterus, of a bluish-red color, is enlarged, especially in its upper two-thirds, to the size of a goose's egg, and is thickened in its antero-posterior diameter. Its walls, filled with venous and arterial blood, are soft and succulent from the transudation of serum. The bundles of muscular fibres are swollen, and the inter-muscular tissue is infiltrated with white blood-corpuscles and a few pus-corpuscles. Extravasations of blood, sometimes larger, sometimes smaller, are usually observed in the connective tissue. These changes are most marked in the innermost layers, where there is a greater abundance of connective tissue, and the inflammatory process is propagated toward the periphery. The endometrium, pelvic peritoneum, and connective tissue are usually involved. The tubes and ovaries are less frequently affected except in the case of gonorrhoeal infection.

SYMPTOMS.—The attack is usually ushered in by a chill, followed by elevation of bodily temperature—a symptom which is apt to persist throughout the course of the disorder. Pain, referred to the lower portion of the abdomen and sacral region, is constant. The sensation may be dull, gnawing, or boring, like the pains in the first stage of labor or abortion, or sharp and lancinating. Tenderness on pressure, indicating involvement of the perimetrium, is marked. The pain is increased in intensity by standing, walking, coughing, straining at stool, or any act which causes an elevation of intra-abdominal pressure. Distressing symptoms arise in connection with the bladder and rectum. Urination is frequent and painful, while the secretion may contain blood. Griping pains are felt along the colon and rectum; the sensation of fulness or the presence of a foreign body excites a frequent or constant desire to defecate, and the act is accompanied with straining.

When acute metritis is caused by wetting the feet in cold water during the period, the menstrual flow may be suddenly arrested, to return after a variable interval. In very rare cases menstruation is permanently suppressed, and even atrophy of the uterus may result. In other cases profuse menorrhagia may occur. Not infrequently this copious hemorrhage is physiological, relieving as it does the congestion of the organ.

Various sympathetic disturbances, as nausea and even vomiting, are occasionally observed.

Acute metritis is frequently complicated by inflammation of the endometrium, pelvic peritoneum, and connective tissue. Under these circumstances the symptoms peculiar to inflammation of the muscular substance are masked. Acute metritis may terminate (1) in resolution, with gradual resorption of the exudation and return of the organ to its normal relations. (2) New connective tissue may be formed, giving origin to induration of tissue and permanent increase in size—the chronic uterine infarct of Kiwisch. The acute inflammation has become chronic. While admitting the possibility of this mode of termination, A. Martin⁸ is of the opinion that a causal nexus is only demonstrable in isolated cases. (3) A very rare mode of termination is suppuration and the formation of abscesses in the muscular tissue. In these cases it is necessary, as pointed out by A. Martin,⁹ to exclude myomata, which have undergone suppuration in the process of retrograde metamorphosis.

⁸ Pathologie und Therapie der Frauenkrankheiten, 1885, p. 181.

⁹ Ibid.

DIAGNOSIS.—The more or less sudden occurrence of a chill, fever, and localized pain and tenderness urgently indicates a careful examination of the pelvic viscera by bimanual palpation. The uterus is exquisitely painful upon the slightest touch, even in the absence of any exudate. The organ is enlarged, especially in its upper two-thirds, and thickened in its antero-posterior diameter. The uterus is softened, resembling in its consistence the organ in the early months of pregnancy. During the stage of active hyperæmia the secretions are diminished in amount; at a later period profuse leucorrhoea, especially in the absence of menorrhagia, is a prominent symptom. The diagnosis of abscess in the uterine walls is difficult, if not impossible, when the collection of pus is small. The gradual enlargement of the uterus, the presence of fluctuation, the indications of pointing, and the constitutional symptoms are usually sufficient to establish the diagnosis when the pus-cavity has attained a considerable size.

PROGNOSIS.—Under appropriate treatment the prognosis of acute metritis is not unfavorable. It must, however, always be guarded, as it will be governed to a great degree by the causation, clinical course, and complications. Acute metritis from wetting the feet in cold water during the period and the like usually terminates in resolution. It is necessary to bear in mind the fact that in rare cases the function of menstruation may be permanently arrested, and even atrophy of the uterus induced. In acute metritis from traumatism the danger of general sepsis constitutes the unfavorable prognostic element. In gonorrhoeal infection the tendency to involvement of the tubes and peritoneum is great; moreover, the condition is apt to recur. In all forms of the disorder the relation to chronic uterine infarct deserves consideration. Finally, death may result from the rupture of an abscess, located in the uterine walls, into the abdominal cavity.¹⁰ Fortunately, these abscesses usually open into the uterine cavity, rectum, or through the abdominal parietes.

¹⁰ Scanzoni, Krankh. d. Weibl. Sexualorg., iv. Aufl. Bd. i., p. 203; Lados, Gaz. médic. de Paris, 1839, p. 605.

TREATMENT.—In general terms, the treatment may be described as vigorously antiphlogistic.

Chrobak¹¹ has pointed out in a detailed manner the absolute necessity of the most rigid attention to antisepsis in all the minor as well as the major operative procedures in gynæcology. The prophylaxis, a subject of vital importance, is limited, so far as the general practitioner is concerned, to the enforcement of absolute cleanliness in all manipulations of the female genito-urinary tract.

¹¹ "Untersuchung. der Weibl. Genitalia und Allgem. gyn. Therapie," Deutsche Chirurgie, Lief. 54.

Absolute rest in bed in the dorsal decubitus, with the pelvis elevated or depressed according to the patient's sensations, is a matter of primary importance. Pain demands for its relief the free use of morphine hypodermatically or opium per rectum. Chloral is a valuable adjuvant.

In the absence of menorrhagia free and repeated scarifications of the cervix are indicated to deplete the uterus. Twelve to twenty leeches applied to the abdomen above the symphysis will measurably relieve the congestion of the perimetrium. At a later stage, when the disorder does not occur at a menstrual epoch, mediate cold-water irrigation, by means of Leiter's modification of Petitgard's tubes, over the hypogastric region is an invaluable therapeutic resource. When the affection occurs during the period, hot compresses applied to the abdomen, hot sitz-baths, and even hot-water vaginal injections, are grateful.

The rectum and sigmoid flexure frequently require evacuation. A simple warm- or hot-water enema will usually secure this result. Occasionally a dose of castor oil is indicated, but drastic cathartics are distinctly contraindicated.

When the acute metritis is caused by traumatism, as in the case of operations on the cervix and curetting of the endometrium, the wounded surfaces demand attention. Under these conditions the neck of the uterus and the uterine cavity require careful antiseptic local treatment.

Abscesses in the uterine walls rarely indicate operative interference, except in case of pointing in the direction of the abdominal cavity. When incision is indicated the pus-cavity is usually large and superficial, and its evacuation involves no especial difficulty.

The treatment of the later stages of acute metritis will be considered in connection with the subject of Chronic Metritis.

Chronic Metritis.

SYNONYMS.—Chronic uterine infarct (Kiwisch); Diffuse connective-tissue hyperplasia of the entire uterus (Klob, C. Braun, Wedl); Induration of the uterus (Wenzel); Engorgement (Lisfranc); Hysteritis, Phlegmasie rouge (Duparcque); Congestion ou engorgement hypertrophique métrite (Becquerel); Interstitial metritis (De Sinéty); Congestive hypertrophy (Emmet); Areolar hyperplasia, Diffuse interstitial hypertrophy, Sclerosis uteri (Thomas, Skene); Subinvolution, Irritable uterus (Hodge).

In the absence of exact knowledge with reference to the ultimate pathology of so-called chronic metritis, it is impossible to frame a definition which cannot be justly criticised. Schroeder's definition answers all practical purposes, and probably contains as few objectionable terms as any other in the literature of the subject.

DEFINITION.—Hyperplasia of the connective tissue of the uterus combined with increased sensibility.

ETIOLOGY.—1. Subinvolution of the puerperal uterus is a frequent cause of chronic metritis. But the number of etiological factors which interfere directly and indirectly with the retrograde metamorphosis of the puerperal uterus is immense. Getting up too early from childbed, inability to suckle the child, too early sexual intercourse, retention within the uterine cavity of blood-clots or placental remains, acute inflammations of the uterus during the puerperium, retroversions and flexions of the puerperal uterus, severe exertion and the like,—are some of the more usual causes in this connection. Involution of the puerperal uterus is effected by contractions of the muscular walls, fatty metamorphosis of the uterine substance, and profuse secretion. Disturbance of any one of these processes may defer indefinitely the return of the organ to its normal relations. When pregnancy is prematurely interrupted the operation of each of these factors is materially modified. Uterine contractions are relatively feeble. The stimulus of a nursing child is also lacking. The albuminoids of the muscular protoplasm are not so readily converted into fat capable of easy resorption. A comparatively large quantity of decidua vera—even in the absence of portions of the foetal envelopes—is retained within the uterine cavity, and the secretory activity of the endometrium is seriously disturbed. Then, women are less careful after miscarriages than labor at term.

Laceration of the cervix uteri—an accident liable to occur in abortion as well as during confinement at term—if at all extensive, usually interferes with the retrograde metamorphosis of the uterus.

2. Continuous or repeated hyperæmia, active or passive, frequently exceeds physiological limits and leads to chronic metritis. Menstrual subinvolution, dysmenorrhoea from organic stenoses, flexions, changes in position with retained menstrual fluid, excessive venery, masturbation, conjugal onanism, chronic endometritis—especially gonorrhoeal—inflammations of the pelvic cellular tissue, chronic oöphoritis, new formations as in the case of carcinoma and myoma,—result in the production of active flexion and venous engorgement. The pernicious effects of conjugal onanism in the causation of chronic uterine infarct have been dwelt upon with particular fondness by Wenzel, Scanzoni, Emmet, Goodell, and numerous other ancient and modern gynæcologists of distinction. Van de Warker,¹² on the other hand, is of the decided opinion that the operation of this etiological factor has been exaggerated. His conclusions are based upon an incomplete gynæcological study of the Oneida Community. Onanism was practised on a colossal scale by this strange people for a number of years. Summing up the results of his imperfect investigations, Van de Warker says: "I can discover nothing but negative evidence relating to the effect of male continence upon the health of the community." It is quite possible that too much importance has also been attached to excessive venery. Fritsch¹³ does not stand alone when he says, "I have examined puellæ publicæ for years, but have not gained the impression that metritis chronica is of frequent occurrence."

¹² Ely Van de Warker, "A Gynecological Study of the Oneida Community," The American Journal of Obstetrics, etc., August, 1884.

¹³ Heinrich Fritsch, Die Lageveränderungen und die Entzündungen der Gebärmutter, 1885, p. 318.

3. Venous stasis from organic hepatic, cardiac, and pulmonary diseases doubtless predisposes to chronic inflammation of the metrium. Constipation, usually habitual with invalids, and an over-distended bladder, are causes which are more frequently and directly operative in the production of vascular engorgement and displacements of the uterus.

4. Various operative procedures upon the cervix, ill-advised and frequently repeated intra-uterine applications, must be included in the list of causative agencies.

5. Chronic metritis is one mode of termination of acute inflammation of the uterine parenchyma. This method of origin, however, is seldom observed except after repeated attacks of acute inflammation, as in the case of gonorrhoeal infection.

The enumeration of possible causes might be indefinitely prolonged. Scanzoni's classical monograph on chronic metritis contains a much larger number. As remarked by Fritsch,¹⁴ "In the elastic bands of his conception of the disease every catarrh, every affection of the uterus, fitted finally snugly into place." The more common efficient causes have been indicated.

¹⁴ Op. cit., p. 299.

PATHOLOGICAL ANATOMY.—Modern pathological doctrines on chronic metritis are largely modifications of the opinions so ably advocated by Scanzoni¹⁵ in 1863. Scanzoni, while fully recognizing the various forms of chronic uterine infarct, simplified the study of the subject by comprehending them all under two stages: I. the stage of infiltration; II. the stage of induration.

¹⁵ Die Chronische Metritis, Wien, 1863.

I. In the first stage the uterine tissue is infiltrated with serum, blood, and fibrin (serös-blutige, serös-faserstoffige Infiltration). The organ is in a state of engorgement oedema, the consequence of active and passive hyperæmia. It is enlarged in volume, altered in shape, reddened and more or less sensitive on pressure, soft and doughy to the sense of touch. The uterus may remain in this condition, or, after a longer or shorter interval, pass over into the stage of induration. Long-continued venous hyperæmia leads with comparative infrequency to induration, although intercurrent inflammations, exudations, and new formations of tissue may produce that effect. This stage cannot be invariably viewed as of an inflammatory character. These enlargements of the uterus are frequently examples of the nutritive disturbances commonly observed in other organs in consequence of long-continued venous hyperæmia. The close correspondence of Scanzoni's stage of infiltration with Emmet's congestive hypertrophy is at once apparent.

II. In the stage of induration a luxuriant growth of connective tissue replaces the specific tissue-elements which are destroyed by a chronic inflammatory process. Early in this stage there may be an actual increase in size of the individual muscular elements. Ultimately, the hypertrophy disappears, the soft and succulent connective tissue becomes fibrillated, and the vessels are narrowed, sometimes obliterated, by its contraction. The uterus, though still enlarged and altered in shape, is of a pale color, anæmic, dry, tough, and hard. Ultimately, the uterus is reduced in size by the cicatricial contraction of the firm, fibrillar connective tissue. On section the tissue is white, of cartilaginous consistence, and the knife creaks as it divides the structures. Scanzoni's stage of induration is thus nearly identical with the areolar hyperplasia, diffuse interstitial hypertrophy, sclerosis uteri, of Thomas and Skene.

Klob¹⁶ a pupil of Rokitansky's, attributes the hyperplasia of connective tissue to nutritive disturbances, considers the terms chronic metritis and chronic infarct anatomically incorrect, and classes the condition among the new formations. Carl Braun¹⁷ and Wedl in 1864 assumed the same position.

¹⁶ Jul. M. Klob, Pathologische Anatomie d. Weibl. Sexualorgane, Wien, 1864.

¹⁷ Lehrbuch d. g. Gynaekologie, Wien, 1881, p. 351.

Klebs¹⁸ is of the opinion that, although the so-called chronic uterine infarct may be of inflammatory origin, in the majority of cases the clinical and anatomical demonstration is lacking. With Scanzoni and Virchow, he distinguishes two forms of the disease, the one consisting in hyperplasia of the muscular elements, the other in a similar change in the connective tissue.

¹⁸ Handbuch der Pathologischen Anatomie, Berlin, 1873, iv. p. 878.

Birch-Hirschfeld¹⁹ supports the doctrine of Scanzoni, that the stage of induration at least is of an inflammatory nature. The connective tissue is formed out of emigrated white blood-corpuscles. Hypertrophy of the muscular elements is also observed in certain cases.

¹⁹ Pathologische Anatomie, p. 1131.

Fritsch²⁰ has materially strengthened the position of Scanzoni by his recent anatomical investigations. Mayrhofer²¹ substantially reproduces Scanzoni's doctrines.

²⁰ Op. cit., p. 309 et seq., Stuttgart, 1885.

²¹ Entwicklungsfehler und Entzündungen des Uterus.

Finally, the great majority of modern clinicians have accepted Scanzoni's teachings as originally uttered or as modified in non-essential details. Schroeder,²² De Sinéty,²³ and A. Martin²⁴ are notable examples of the truth of this statement.

²² Carl Schroeder, Handbuch der Krankheiten d. Weibl. Geschlechtsorgane, Leipzig, 1881, p. 91.

²³ L. de Sinéty, Manuel practique de Gynécologie et des Maladies des Femmes, Paris, 1879.

²⁴ Op. cit., Wien, 1885, p. 185.

The hyperplasia of the connective tissue may be diffuse or circumscribed. It may be limited in development to the collum or corpus uteri. The perimetrium is usually thickened, and other signs of chronic inflammation of that structure are usually present. Chronic endometritis is a constant accompaniment. The pelvic connective tissue is not commonly involved. The plexus pampiniformes and utero-vaginales frequently undergo varicose dilatation.

SYMPTOMS.—The onset of the disease is so insidious and protracted that it is difficult to determine the exact order of occurrence of the symptoms in point of time. Then the complications are so numerous and important that the symptoms of the chronic metritis are frequently masked. A sensation of weight, fulness, or pressure within the pelvis may direct the patient's attention to her condition. This sensation may increase to such a degree that the woman complains of heavy, dull, dragging pains, referred to the centre of the pelvis or the sacral region. Backache is a constant and distressing symptom. Pains radiating up over the abdominal parietes and down the thighs are frequently experienced. Coitus may be productive of acute distress. When the uterus is anteverted, pressing against the bladder, ischuria is the usual result. Constipation, usually present as one of the etiological factors, is aggravated by the retroversion or retroflexion of the top-heavy uterus. Under these circumstances one or both ovaries may be drawn down along with the prolapsed, retroverted uterus, and add materially to the woman's discomfort. The act of defecation is painful; the woman avoids the water-closet, days and even weeks elapsing between evacuations.

Disturbances of the menstrual function are constant. All forms of dysmenorrhoea, including dysmenorrhoea membranacea, are liable to occur. Menstruation is usually profuse, giving origin to menorrhagia, which usually results in the production of an alarming degree of anæmia. The periods are irregular in recurrence and duration. The periodic discharge of blood may last from one to three weeks, and then cease, to reappear after a variable interval of from six to eight weeks. In other cases menstruation may last the usual length of time, but recur every two or three weeks. Amenorrhoea may be observed in the stage of induration.

Priestly,²⁵ Fasbender,²⁶ Fehling, and numerous other clinicians have called attention to intermenstrual pain (règles surnuméraires) as a tolerably constant symptom of chronic metritis. From fourteen to fifteen days after and before the regular time for menstruation vague intrapelvic pains are complained of, and the woman is of the opinion that the monthly flow of blood is about to begin. The pains, however, are not so severe, and do not last so long, as those of menstruation. Occasionally bloody mucus may escape from the vagina. Fehling ascribes this intermenstrual pain to the swelling of the mucous membrane preparatory to the next monthly discharge of blood. The symptom is not at all pathognomonic, as it occurs in connection with oöphoritis and other pathological conditions.

²⁵ Brit. Med. Journ., 1872, p. 431.

²⁶ Zeitschrift f. Gebürtskulfe und Frauenkrankheiten, i. 1.

As the result of the chronic endometritis, which usually follows parenchymatous inflammation, metrorrhagia is frequently observed. Leucorrhoea, more or less profuse, is a constant symptom. Opinions vary extremely as to the systemic reaction following chronic metritis. General failure of nutrition, functional disturbances of the gastro-intestinal canal, hysteria, headache,²⁷ facial neuralgia (Barnes), coccygodynia, vaginodynia, skin diseases, alopecia (Hebra), and a host of other affections, have been ascribed from time to time to the direct influence of chronic uterine infarct. Doubtless, the condition under discussion plays an important rôle in the production of these and other disorders. But the position is utterly untenable at the present day that chronic parenchymatous inflammation of the uterus is the efficient cause in the absence of all other etiological factors.²⁸

²⁷ Peaselee, "Uterine Headache," American Medical Monthly, 1860.

²⁸ Fritsch, op. cit., 1885, p. 323.

Intercostal neuralgia and mastodynia, with swelling of the breasts and darkening of the areolæ, are phenomena of such constant occurrence in connection with chronic uterine infarct that a direct causal nexus is in a high degree probable. The investigations of Krause²⁹ have established the fact of anastomotic communication between the arteries supplying the mammary gland and those distributed to the uterus. The perforating branches of the internal mammary artery supply in part the mammary gland. The superior epigastric artery, one of the terminal branches of the internal mammary, anastomoses with the inferior epigastric, which arises from the external iliac a few lines above Poupart's ligament. The inferior epigastric sends off a spermatic branch which passes along the round ligament and anastomoses with the ovarian artery derived from the aorta, and the uterine artery derived from the anterior trunk of the internal iliac. The nervous communication is effected through the sympathetic and spinal nerves. There is nothing remarkable, therefore, in the occurrence of intercostal neuralgia, mastodynia, and nutritive disturbances in the mammary gland as the result of chronic parenchymatous inflammation of the uterus. The intercostal neuralgia and mastodynia are examples of reflected neuroses the result of compression of nerve-fibres by the infiltration or of an ascending neuritis (Fritsch).

²⁹ Specielle und Makroskopische Anatomie, Hannover, 1879.

PHYSICAL SIGNS OF CHRONIC METRITIS.—Bimanual palpation prior to the stage of cicatricial contraction reveals alterations in size, shape, position, consistence, and sensibility of the uterus. Variations in size are extreme. Veit³⁰ has recorded a case in which the fundus extended two inches above the umbilicus. The uterus is usually thickened, especially in its antero-posterior diameter. As regards position, the organ may be prolapsed, elevated, or remain in situ. The consistence will depend upon the stage of the disease. During the stage of infiltration the organ is soft and imparts a doughy sensation to the examining finger. During an exacerbation of acute inflammation the vagina is hot and dry; the uterus is swollen with blood and very sensitive on pressure. During the intervals between exacerbations no change in sensibility is noticed. The sound demonstrates a varying degree of elongation of the uterine cavity. During the second stage, after cicatricial contraction of the connective-tissue elements, the uterus is relatively small, hard, and insensible.

³⁰ Frauenkrankheiten, 2 Aufl. p. 367.

The cervix is hard or soft according to the time of examination. In virgins or women who have not borne children enlargement is of relatively infrequent occurrence. In multiparæ, especially in cases of bilateral cervical laceration, the increase in volume is great. The mucous membrane of the cervical canal is everted and studded with minute cysts—distended follicles.

The influence of chronic metritis upon conception is not direct. When the endometrium is not seriously involved the condition seems to exercise no untoward influence. However, associated with chronic uterine infarct as complications we have endometritis, salpingitis, oöphoritis, perimetritis, and displacements, pathological states which may obviously cause sterility.

When conception does occur, abortion follows with relative frequency. The reason why is not clear. The chronic endometritis may interfere with the development of the decidua; the parenchyma may not be able to undergo evolution. When pregnancy reaches its normal termination, labor is not materially influenced by the pathological condition of the uterus, but complications are liable to occur during the puerperium. Postpartum hemorrhages which do not readily yield to ergot are observed as the result of the deficiency in muscular elements. The hyperplasia of the connective-tissue elements and destruction of the muscular tissue is a distinct predisposing cause of complete or incomplete uterine inversion. Subinvolution is increased. Menstruation recurs soon after pregnancy, and the chronic metritis is aggravated.³¹

³¹ A. Martin, op. cit., Wien, 1885, p. 189.

Occasionally, gestation, parturition, the puerperium, and lactation seem to exercise a favorable influence on the state of the parenchyma. In exceptional cases all traces of the original chronic metritis disappear with the puerperium. The connective-tissue hyperplasia may undergo the same involution to which the hypertrophied muscular tissue is subject. This favorable termination of the disease is seldom observed during the stage of induration.

TERMINATIONS.—I. Chronic metritis may terminate during the stage of infiltration in resolution. This mode of termination is rare. It is observed occasionally as the result of involution in the puerperal uterus. Judicious treatment in favorable cases may reduce the size of the uterus and relieve all distressing symptoms. Recidiva of the disease are liable to occur, however, and all traces of the former condition seldom disappear.

II. Usually, the condition persists, with acute exacerbations, through years, until cessation of menstruation and ovulation occurs. Under the influence of the change of life the symptoms may gradually disappear and the uterus may undergo senile atrophy. In some cases chronic uterine infarct seems to defer the climacteric changes. Finally, the disease may continue after the menopause, usually with abatement in the severity of the symptoms.

III. The morbid condition may terminate in induration. The uterus becomes comparatively small, hard, and insensible. Amenorrhoea may be the result. This process may be viewed as a relative cure, since it is attended, as a rule, with amelioration of all the troublesome symptoms.

DIFFERENTIAL DIAGNOSIS.—It is not always an easy matter to institute a differential diagnosis between chronic metritis and pregnancy and fibroid tumors by bimanual palpation. Alterations in the volume, form, position, consistence, and sensibility of the uterus occur in pregnancy as in chronic metritis. But in pregnancy the uterus, particularly in its vaginal portion, is softer; the organ is not so sensitive; the cyanotic hue of the vaginal mucous membrane is more marked; arterial pulsations in the vagina are more evident; the uterus enlarges more rapidly; finally, there is the history of the case. Pregnancy may occur, however, in a chronically inflamed uterus, and this fact must be borne in mind.

The alterations in the size of the uterus are usually circumscribed in fibroid tumors. One wall is thickened; the other retains its normal relations. In submucous fibroids the cervix is shortened; in chronic metritis it is usually enlarged. In both submucous and interstitial fibroids the cavity of the uterus is encroached upon—a fact to be determined by the use of the sound. The history of the case will throw some light upon the differential diagnosis. Frequently, however, it is impossible to exclude fibroids by any of the means already mentioned. Dilatation of the cervix, and the careful examination of the walls by the finger introduced into the uterine cavity, will clear up the diagnosis in the most obscure case.

PROGNOSIS.—The prognosis with reference to life is favorable. The duration of life however, may be abbreviated in exceptional cases by disturbances of nutrition, anæmia the result of menorrhagia and metrorrhagia, extension of the inflammation to the peritoneum, and the like—conditions which predispose to some intercurrent affection.

Although the immediate danger of death is minimal, the woman is rendered wretched by the frequent exacerbations of acute inflammation and other symptoms already mentioned. The spontaneous disappearance of the affection with the puerperium or menopause is of such seldom occurrence as to have but slight bearing on the general rule.

Under judicious treatment disappearance of the more distressing symptoms may be confidently expected during the stage of infiltration. The outlook is especially favorable in cases of puerperal subinvolution in the absence of chronic inflammations of the endometrium and parametrium. A perfect restitution of the uterus to its normal condition is so seldom effected by any rational therapy that for practical purposes this desirable result may be excluded from consideration. Recidiva of the disease are liable to occur at any time.

TREATMENT.—Prophylaxis.—Very much can be done to prevent the occurrence of chronic metritis. A careful consideration of the etiology of the disease will at once suggest the principles of prophylactic treatment. The conduct of the second stage of labor, the puerperium, lactation, the hygiene of menstruation, are subjects especially significant in this connection. Antecedent acute metritis and endometritis under a rational therapy usually terminate in resolution, and their pernicious influences as etiological factors may be avoided, or at least modified, in the large majority of cases. The early rectification of uterine flexions and displacement is urgently indicated in view of the probable consequences.

Uncomplicated chronic metritis is such a rare affection that efforts at curative treatment are seldom addressed to the condition of the parenchyma, to the exclusion of the endometrium, perimetrium, and parametrium. Certain special indications, however, exist in the case of chronic uterine infarct, and the discussion of treatment is limited here to their consideration.

1. Local Treatment.—In view of the pathology of the condition, local treatment, especially in the first stage, is antiphlogistic.

Hot-Water Vaginal Douche.—The irrigation of the vagina with hot water, of different degrees of temperature according to the indications in the concrete case, deservedly occupies the high position in American gynæcological therapeutics which Emmet³² in particular has assigned it. The smooth muscular fibres of the uterus are excited to contract, and the whole pelvic circulation is directly or indirectly influenced. During the stage of infiltration—Emmet's congestive hypertrophy—hot-water vaginal irrigation is simply an invaluable adjuvant. But to secure the maximum benefit from this remedy it must be rationally employed. With reference to posture, Emmet recommends the dorsal decubitus, with elevation of the hips, or, better, the genu-pectoral position. The temperature of the water should be rapidly elevated from blood-heat to 110° F., or to as high a degree as the patient can tolerate. The quantity of water will vary with the stage of the treatment and the improvement in health of the patient. It is customary to begin the irrigations with one to two gallons of water, and to increase or decrease the quantity according to circumstances. Two irrigations per diem—one at night before going to bed, one in the morning upon rising—are usually sufficient. Fritsch³³ has tried on an extensive scale the plan of continuous vaginal irrigation with hot water through five and even ten hours, but has obtained better results with the simple periodic vaginal douche as recommended by Emmet.

³² Principles and Practice of Gynæcology, 3d ed. 1884, pp. 85, 113.

³³ Op. cit., 1885, p. 337.

During the stage of induration, when the muscular elements have been destroyed and replaced by connective tissue, the beneficial effects of the hot-water douche are decidedly less evident. Nor is the plan applicable to all cases during the stage of congestive hypertrophy. General nervous excitement, insomnia, and even positive intrapelvic pain, sometimes, though rarely, may result. The range of therapeutic application of the hot-water vaginal douche is largely empirical.

Local Depletion.—The local bloodletting of from a drachm to one ounce of the fluid, repeated according to the indications every three or four days, ranks next to the hot-water vaginal douche in importance as an antiphlogistic agent. This plan of treatment is of especial value as an adjuvant during the stage of infiltration in cases of menorrhagia, metrorrhagia, exacerbations of acute inflammation, and the like. Local depletion, however, is a double-edged sword. It may cause an increased determination of blood to the uterus and aggravate the pathological condition already existing. This effect is observed when the bloodletting is practised at too short intervals.³⁴ Thus, frequent scarifications of the cervix constitute a most important therapeutic resource in the treatment of certain forms of atrophy of the uterus.

³⁴ A. Martin, op. cit., 1885, p. 59.

Local depletion of the cervix is effected by scarification, puncture, leeches, wet and dry cupping. Scarification and puncture have almost entirely superseded the other two methods.

Local depletion has fallen into a state of comparative disuse in America. In the Woman's Hospital of New York³⁵ it has almost completely passed out of vogue. In Germany, however, it constitutes the basis of all methods of treatment. Schroeder, A. Martin of Berlin, H. Fritsch of Breslau, Carl Braun, Spaeth, and Chrobals of Vienna unite in enthusiastic advocacy of its intelligent employment in suitable cases.

³⁵ T. Gaillard Thomas, Diseases of Women, 5th ed., 1880, p. 334.

Glycerin Tamponade.—Sims many years ago called attention to the employment of cotton tampons saturated with glycerin in the treatment of chronic metritis and kindred affections. In virtue of its avidity for water the glycerin tampon, when placed in the vagina, provokes a profuse aqueous discharge. The albuminoid constituents of the blood are not affected, while the capillaries are drained of their aqueous elements. Emmet³⁶ has substituted oakum for absorbent cotton. Oakum, when saturated with glycerin, becomes soft as a sponge, is perfectly antiseptic, and will remain odorless in the vagina a much longer time than cotton. Glycerin dissolves the salts more readily than water. Boric acid (1:10), potassium iodide (5:100), iodoform, chloral, and a variety of substances may be applied locally by means of this menstruum. Glycerin, employed in conjunction with hot-water vaginal irrigation and scarification, or used alone in cases contraindicating these procedures, is an important addition to our therapeutic resources.

³⁶ Gynæcology, 1884, p. 128.

Local Alteratives.—Much importance is attached in the United States to the application of various alteratives to the vaginal portion and endometrium in cases of chronic uterine infarct. They may accomplish good results indirectly—for example, by curing the accompanying endometritis—but it is doubtful whether they have any direct effect in hastening the resorption of the infiltration.

The vaginal vault and intravaginal portion of the cervix are usually painted with the compound tincture of iodine; mercury, potassium iodide, iodoform, and other substances are introduced into the vagina by means of vaseline, gelatin, and cacao butter.

Operative Treatment.—1. Repair of Lacerations of the Cervix.—The importance of the repair of lacerations of the cervix for the cure of chronic uterine infarct and allied conditions was recognized by Emmet in 1862. In the autumn of 1862 he devised and performed the operation, which is now known the world over as Emmet's operation. This highly original and valuable surgical procedure has been but little modified in the years which have intervened since its first full description in 1869.

2. Amputation of the Collum Uteri.—Carl Braun³⁷ and Wedl in 1864 pointed out the fact that amputation of the neck of the chronically inflamed uterus is frequently followed by a more or less complete involution of the whole organ, resembling very closely the reductive metamorphosis of the puerperal uterus. August Martin in recent years has called attention to Braun's observation, and at the Naturforscherversammlung in Cassel described a series of seventy cases in which amputation of the collum uteri had been performed for the relief of chronic metritis. As an ultimate resort in extreme cases, amputation of the neck of the uterus is now a generally well-recognized operative procedure.³⁸

³⁷ Wiener Med. Jahrbücher, Wien, 1864.

³⁸ H. Fritsch, op. cit., 1885, p. 343.

3. Castration.—At a comparatively recent date a determined effort has been made to include desperate cases of chronic metritis under the indications for the performance of oöphorectomy. Numerous and distinguished surgeons have taken this advanced position. But at the present time the cases in which the operation has been performed are too few in number and too recent to warrant positive deductions with reference to the effects of the operation.

2. General Treatment.—It is not possible to adequately discuss the subject of the general or constitutional treatment of chronic metritis in the limited space at our command. It is scarcely necessary to add that the subject is of vital importance, and more frequently neglected than the local treatment. The indications for therapeutic aid are usually apparent, and are not always peculiar to the condition. Attention has been directed, in other portions of this work, to the importance of the observation of hygienic laws, in the widest sense of that expression, with respect to diet, rest, clothing, recreation, personal cleanliness, temperance in sexual intercourse, and other bodily habits.

Habitual constipation, involving as it does engorgement of the portal system and pelvic veins, demands especial consideration. In the absence of regular daily alvine dejections the most elaborate plan of local and constitutional treatment will fail to effect amelioration of symptoms. Diet, exercise, and the like are not sufficient, as a rule, to correct this most obstinate habit. Among remedial agents, senna, rhubarb, cascara sagrada, and the milder laxatives deserve particular mention. The compound licorice powder and confection of senna of the U. S. Pharmacopoeia are comparatively innocent in their effects, even when used through long periods of time. Aloes must be employed with a certain amount of caution. As pointed out by August Martin,³⁹ when there is a disposition to uterine hemorrhages the drug, in the exercise of its well-known influence on the pelvic circulation, may increase this tendency. Clysters may be employed to advantage in connection with hygienic and medical means.

³⁹ Op. cit., p. 195.

Ergot, hydrastis canadensis, potassium iodide, ammonium chloride, strychnia, are among the remedial agents which are supposed to have some direct effect upon the condition of the uterine parenchyma. Ergot may be exhibited by the mouth or hypodermatically. Squibb's fluid extract, while an active and tolerably agreeable preparation, is not as effective as the decoction employed on an extensive scale in many of the German hospitals, and the formula of which we append:

Rx.	Secalis cornuti recent. pulver.,	15.0
	Alcohol.,	5.0
	Acidi sulphurici,	2.0
	Aquæ,	500.0
	Coque ad	200.0
	Ne cola.
	Adde Syr. cinnamom.,	30.0

Dose: Two to three teaspoonfuls, pro re nata. This unfiltered decoction is extremely distasteful, and its continued use is not without effect upon the gastric mucous membrane. It is, however, physiologically very active. Subcutaneous injections of Squibb's aqueous extract of ergot may be occasionally employed with benefit to keep up the impression of the remedy when exhibition per os is interrupted. Schatz speaks in high terms of the fluid extract of hydrastis canadensis in doses of fifteen to twenty drops two or three times daily.

All European writers ascribe an important influence to the numerous watering-places and baths of the Continent in the treatment of chronic uterine infarct. The rigid observance of hygienic rules, the imbibition of enormous quantities of water more or less impregnated with salines and carbonic acid, the frequent bathings, exercise, and recreation, undoubtedly effect amelioration of symptoms in many desperate cases.

Acute Endometritis.

ETIOLOGY.—An acute inflammation of the mucous membrane of the uterus is a rare affection before puberty. The acute infectious diseases play an important rôle in the production of the condition. The acute exanthems—smallpox, measles, scarlet fever, cholera, typhus, typhoid, and relapsing fever, certain forms of malarial fever—deserve mention in this connection. Probably owing to some change in the constitution of the blood, these diseases predispose to the hemorrhagic form of acute endometritis. The rapid cooling off of extensive areas of the skin surface during menstruation frequently leads to an acute inflammation of the endometrium, with suppression of the flow as one of the first symptoms. Gonorrhoeal infection and sepsis are most important causative factors. Ill-advised therapeutic procedures, as in the case of acute metritis, must be included in the list of causative agencies. Finally, acute endometritis may be caused by various poisons. Among toxic agents which may give origin to the condition under discussion phosphorus is especially noteworthy.⁴⁰

⁴⁰ Hausmann, Berl. Beitr. z. Geb. u. Gyn., Bd. i. S. 265.

PATHOLOGICAL ANATOMY.—The entire lining membrane of the uterine cavity may be involved in the inflammatory process; usually, the mucosa of the body and fundus is affected, the mucosa of the cervical canal remaining normal. The mucous membrane is of a dark-red color, swollen, softened, and presents a velvety appearance. Its connection with the muscularis is loosened, so that it can frequently be stripped off with the handle of a scalpel. Minute extravasations of blood are visible in the superficial layers and on the surface. The interglandular connective tissue is the seat of the inflammatory process. The glands are involved secondarily. The ciliated epithelium is destroyed and cast off at an early stage. The bloody discharge from the uterine cavity becomes serous, and finally purulent, during the progress of the condition. The cervical secretion becomes thin, turbid, and profuse.

The inflammatory process is seldom limited to the endometrium. It involves, as a rule, the tubal mucous membrane, the uterine parenchyma, and the perimetrium.

DIAGNOSIS.—The symptoms resemble closely in kind, but differ in degree from, the appearances in acute metritis. The uterus is smaller and not so painful on pressure. The endometrium is sensitive to the slightest touch—a fact elicited upon the passage of the sound. The characteristic symptom is the discharge from the uterine cavity of a more or less profuse secretion possessing the character already mentioned. An absolute differential diagnosis is impossible, nor is it necessary, seeing that the treatment of the two conditions is nearly identical.

PROGNOSIS.—Acute endometritis terminates in resolution or chronic inflammation. The latter mode of termination is of more frequent occurrence, particularly in the presence of gonorrhoea, sepsis, and the like as etiological factors. The disease endangers life when the peritoneum is involved by the propagation of the inflammatory process along the tubes or through the uterine parenchyma. Then the acute endometritis may be the starting-point of general septic infection through the media of the veins and lymphatic vessels.

TREATMENT.—Absolute rest in bed, the relief of pain by morphine, the evacuation of the bowels by enemata or mild laxatives, the free imbibition of bland mucilaginous fluids for the vesical tenesmus,—are measures which usually fulfil all indications for treatment. Even in the case of gonorrhoeal infections astringent applications to the endometrium are contraindicated. Usually, various complications mark the endometritis, the starting-point of the pathological condition, and these complications demand more active interference.

Chronic Endometritis.

ETIOLOGY.—Attention has been called to the etiology of chronic metritis in a somewhat detailed manner. The limits of this paper will not admit of adequate mention even of the more common causative factors of chronic endometritis. All the conditions which determine an active fluxion or passive hyperæmia of the uterus may operate as causative factors. Hypersecretion of mucus is frequently observed in chlorotic, scrofulous, and tuberculous females. Syphilis and gonorrhoea are potential causative agents. Climate seems to exercise a more or less direct influence. Thus, we are informed by Schroeder⁴¹ that chronic endometritis is observed with relative frequency in damp, cool regions, such as Holland, Belgium, and certain parts of England. Europeans who reside in hot climates—for example, the Englishwomen living in India—are said to be affected with leucorrhoea to a degree entirely out of proportion to local or constitutional causes.

⁴¹ Handbuch der Krankheiten der Weiblichen Geschlechtsorgane, 1881, p. 111.

PATHOLOGICAL ANATOMY.—An analogy of striking character exists between the structural changes in chronic endometritis and chronic metritis. In chronic endometritis, as in chronic metritis, it is possible to clearly distinguish two stages in the inflammatory process. In the first, or stage of infiltration, a more or less acute inflammation is observed, which involves, primarily, the interglandular connective tissue; secondarily, the glands themselves. When the stage of infiltration does not terminate in resolution with the resorption of the exudate, the newly-formed connective-tissue elements contract, and the glands are to a greater or less degree obliterated.

1. Chronic Catarrhal Endometritis.—The endometrium during the first stage is swollen, vascular, soft, and succulent. Small extravasations of blood and pigmentary deposits from ecchymoses are observed in the interacinous connective tissue. The surface of the mucous membrane is smooth or roughened in spots. The orifices of the glands are visible. The mucous membrane of the cervix is infected, its transverse folds distended, the follicles filled with mucus, the canal plugged with tenacious turbid secretion; the vaginal portion is enlarged, spongy, and its mucous membrane exhibits hypertrophic changes in the papillary body. The os externum is frequently patulous. The uterine walls having undergone excentric hypertrophy, the cavity is usually enlarged, and contains a translucent alkaline secretion which resembles mucus.

Microscopical examination of the endometrium reveals a variety of structural changes. A luxuriant development of embryonal connective-tissue elements is observed with relative frequency in the interacinous connective tissue. Olshausen has applied the term chronic hyperplastic endometritis to this condition. The term chronic interstitial endometritis has been more generally accepted. While the newly-formed connective-tissue elements are soft and succulent, hemorrhages are frequent.

Changes in the glandular structures may become more prominent features than alterations in the connective tissue. The laminæ of the glands and the cells of the acini increase in size. The glands branch, frequently resulting in the production of a dendritic network. Schroeder and Carl Ruge have termed this glandular endometritis diffuse adenoma.

The thickness of the mucous membrane may increase in spots from three or four millimeters to fourteen or fifteen millimeters, and there is produced a form of chronic endometritis which is known as fungoid or polypoid.

Under the name endometritis villosa Slavianski described in 1874 a condition of the uterine mucous membrane which consists in a papillary growth of the endometrium with myxomatous degeneration of the vessel tunics.

During the stage of induration the ciliated epithelium, destroyed and cast off during the stage of infiltration, is replaced by cells which resemble squamous epithelium. The utricular glands, with dilated cavities, are flattened out, entirely obliterated, or present the appearance of shallow crypts. The secretion is gradually diminished, until finally the endometrium is converted into a layer of connective tissue.

Under the names erosion, ulceration, granulation, and the like a variety of pathological conditions, entirely distinct from, sometimes in connection with, cervical laceration and ectropium, are included. The flattened epithelium covering the vaginal portion may be cast off, and replaced by the dark-red subjacent cylindrical epithelium, giving origin to the condition known as simple erosion. Occasionally, glandular canals, formed out of these cylindrical cells, and penetrating the mucous membrane in every direction, present the appearances of papillary erosion; and the condition has accordingly been termed by Carl Ruge papillary ulcer. Cervical secretions may stagnate in these glandular tubes, retention-cysts appear, and the condition technically termed follicular erosion results. In all forms of cervical erosion or laceration the secretions are increased in amount and altered in physical and chemical characters during the stage of infiltration. In a later stage of the disease the hyperplasia and subsequent contraction of the connective-tissue elements may result in the total obliteration of all traces of glandular structure. There is a certain amount of probable evidence in favor of the view that these changes in the cylindrical cells normally situated beneath the squamous epithelium covering the vaginal portion may terminate in malignant disease. These erosions, in the present state of our knowledge, must be viewed as symptomatic of chronic endocervicitis.

2. Dysmenorrhoea Membranacea.—The exfoliation and casting off of large pieces, or even of the superficial layers, of the entire endometrium during menstruation has been observed from the days of Morgagni up to the present time. Peter Frank pointed out the resemblance between this exfoliation and the membrana caduca. Simpson, recognizing the sieve-like perforations caused by the utricular glands, termed the condition exfoliation of the hypertrophic mucous membrane. Virchow erroneously termed the membrane decidua menstrualis. Olshausen, Wyder, and v. Recklinghausen (1877) have demonstrated the truth of Simpson's view, and have shown that the condition must be regarded as a symptom of a series of endometritic inflammatory processes. In all cases in which a decidual membrane is cast off the diagnosis of abortion must be made, whether the pregnancy be intra-uterine or extra-uterine.

Wyger has reported a case in which syphilis was regarded as an etiological factor. This observation has not been confirmed.

3. Chronic Croupous Inflammation of the Endometrium is sometimes observed in connection with carcinoma of the corpus. It may follow gangrenous vaginitis in diphtheria and the acute infectious diseases. The interacinous connective tissue is infiltrated with fibrinous materials, and extravasations of blood are everywhere visible. The superficial layers of the mucous membrane become gangrenous, are cast off, and occasionally the entire intra-uterine expanse is converted into a wound surface.

DIAGNOSIS.—The symptoms of chronic endometritis and endocervicitis are usually masked by the appearance of the accompanying chronic metritis. Intrapelvic pains, disturbance of the menstrual function, extra-menstrual hemorrhages, the presence of a more or less profuse leucorrhoea, are signs which urgently indicate bimanual palpation.

The catarrhal secretion from the utricular glands may be imprisoned within the uterine cavity by a functional or organic stricture of the internal os, resulting in periodic discharges of a thin, translucent alkaline fluid, readily distinguishable from the thick, tenacious cervical mucus. In certain cases, particularly in old women, the blenorrhoeal secretion may be permanently retained within the uterine cavity, constituting the condition hydrometra.

The introduction of a small sharp spoon within the cavity of the uterus will enable the observer to remove sufficient tissue for microscopical examination without entailing the slightest injury on the patient. A positive diagnosis can be made in this way, and a rational therapy instituted.

Digital and specular examinations disclose the condition of the vaginal portion of the cervix. The amount and physical characters of the cervical secretions are items of important diagnostic moment. In suspicious cases of cervical erosion a small bit of tissue may be cut away from the surface and subjected to microscopical examination.

Secondary disturbances in connection with the gastro-intestinal canal and nervous system occur in chronic inflammations of the endometrium, as in the case of chronic uterine infarct.

PROGNOSIS.—Chronic inflammations of the corporeal and cervical mucous membrane seldom threaten life directly. The continuous loss of blood and serum, however, may produce a condition of profound anæmia and render the individual more susceptible to intercurrent disease.

Then the hyperplastic condition of the endometrium is always an occasion for anxiety. The relation between polypoid and fungoid growths of the corporeal mucous membrane, erosions of the vaginal portion of the cervix, and malignant new formations is not settled. The possibility of malignant residua, however, must be admitted.

Sterility, acute and chronic decidual inflammations, adherent placenta, disturbances in the involution of the puerperal uterus, and the like—direct results of chronic endometritic inflammation—are conditions which confer an unfavorable element upon the prognosis.

Finally, while it is possible to effect a material amelioration of all the symptoms by a judicious general and local treatment, a complete restitutio ad integrum is seldom or never achieved. Recidiva are always liable to occur.

TREATMENT.—Prophylaxis.—The remarks made with reference to the prevention of chronic uterine infarct apply with equal force to the prophylaxis of chronic corporeal and cervical endometritis.

Curative.—Of chief importance, in the very large majority of cases, is the subject of general treatment. Many cases of chronic catarrhal endometritis are improved by the regulation of the functions of the gastro-intestinal canal, skin, kidneys, and hæmatopoietic viscera in the absence of all local treatment. This statement holds true with particular force when scrofulosis, tuberculosis, syphilis, and the like are chief etiological factors.

Local Treatment.—The methods of local treatment at the present time are infinitely various. For convenience of description they may be collected under three headings:⁴²

I.	The washing out of the uterine cavity;
II.	The cauterization of the uterine cavity;
III.	The curettement of the uterine mucous membrane.

⁴² H. Fritsch, op. cit., 1885, p. 419.

To Schultze, in particular, are we indebted for methods of washing out the cavity of the uterus. The cervical canal is dilated by means of the finger, tents, or metallic instruments, and the mucous membrane lining the cavity of the uterus is cleansed with dilute solutions of carbolic acid, boric acid, bichloride of mercury, and other solvent and antiseptic fluids.

Cauterization is usually effected at the present time by the application of pure tincture of iodine, iodine with glycerin, or carbolic acid, to the endometrium. Bandl's canulæ for the washing out of the uterine cavity with solutions of alum and cupric sulphate are valuable instruments in this connection. The application of the solid stick of nitrate of silver and intra-uterine injections of liquor ferri are gradually passing into disuse.

The curettement of the diseased endometrium has been rapidly gaining ground within recent years, and now constitutes the most reliable method of treatment in obstinate cases in which local interference is indicated at all. Martin, Düvelius, and other clinicians have abundantly established the fact that, after the mechanical removal of the old diseased mucous membrane, a new endometrium of relatively normal functional activity is formed.

The number of operative procedures for the relief of chronic endocervicitis is enormous. In the majority of cases occurring among multiparæ it will be found that the condition is aggravated, if not caused, by cervical laceration with ectropium. Under these circumstances, and under the indications and conditions insisted upon by the author of the procedure, Emmet's operation will alleviate, if it does not cure, the pathological state of the mucous membrane.