bands about the uterus, after peri- or para-metritis, from tumours of adjoining structures, from habitual over-distension of the bladder and bowel, and from diseases of the liver, lungs, and heart, which also produce induration of the other pelvic organs. The uterine parenchyma is also secondarily affected by extension of the inflammation from the endometrium.

The symptoms of simple uncomplicated chronic metritis (which is very rare) consist only of sacral pain, a feeling of weight and tension in the pelvis, and when the enlargement of the uterus is great, frequent desire for micturition. Increased menstrual flow (menorrhagia) and increased uterine secretion point to affection of the endometrium which overshadows the chronic metritis. And on the removal of the former the symptoms of chronic metritis disappear.

The diagnosis of chronic metritis may be decided upon when the uterus is enlarged and tender. When the uterus is not fixed, the normal bend of the anterior surface is lost, that is, the uterus is in a position of anteversion. Pregnancy must be specially taken into question when considering the differential diagnosis. In this condition, however, the uterus is much softer and more yielding. If the diagnosis of chronic metritis has been made, it is necessary to note which of the almost always accompanying complications are present, since the symptoms of chronic metritis disappear with the successful treatment of the complications.

Treatment. - Suitable treatment during the puerperium, and especially in connection with abortion, is necessary as a prophylactic means. More care should be bestowed upon the training of girls at the time of puberty SO as to ensure regular habits of defæcation and of micturition. Displacements of the uterus must be rectified. Cicatricial bands following peri- and para-metritis should be stretched by massage, which should also be applied to the uterus itself. Massage causes resolution of recent inflammatory exudations, and by exciting uterine con

traction, removes the accompanying hyperæmia. Hot vaginal douches (up to 50° C.) (122° F.), dilatation of the uterus by tents or by tamponading with iodoform gauze, curetting followed by the use of a solution of chloride of zinc (to 50 per cent) as a caustic, all act in the

arose.

Fig. 63.

same manner. This last method of treatment essentially cures the endometritis from which the metritis primarily It tends to shorten the period of local gynæcological treatment, and thus lessens the probability of subsequent neuroses. In quite chronic cases where the

uterus is very indurated and enlarged this treatment is not successful. Amputation of the portio is indicated in these cases, and this, according to C. Braun and A. Martin, leads to involution of the whole uterus. The excision of a wedge-shaped piece from the whole anterior cervical wall, after opening the anterior vaginal vault, is

technically more simple and practical. The author has performed this in a series of cases. If the cervical canal is very big, a piece of the mucous membrane is removed at the same time (Fig. 63), if it is normal in size the wedge is only carried up to the mucous membrane. The space is closed by 5-7 interrupted sutures, those passing through the supravaginal portion are buried. The wound in the

vaginal vault, which is naturally a transverse one, is closed with continuous catgut sutures transversely, and only after vaginal fixation (see operative treatment of retroflexion) is it closed sagittally (Fig. 64). By this operation a normal slender cervix is obtained, which later cicatricial contraction will not alter. Para- and perimetritis posterior, which have commonly followed the hitherto used method of amputation of the portio (p. 120) cannot occur. As "after-treatment the various bath and water cures are used (brine, mud, chalybeate, and sea-baths, iron, and purgative waters). The benefits derived from these are due to the altered and (hygienically) more suitable methods of living which of necessity accompany their use.

Inflammation of the Endometrium

(Endometritis)

This may be localised in the cervix alone-(endometritis cervicis); in the body alone-(endometritis corporis), or in both cervix and body.

Acute Endometritis.

as

Acute endometritis arises from the same causes those given for acute metritis. As a secondary condition it is found in infectious diseases and phosphorus poisoning; the inflamed mucous membrane exhibits numerous hæmorrhages (Slavjansky). The diagnosis is based upon the intense redness and swelling of the visible cervical mucous membrane, upon the profuse purulent or foul secretion, and on the tenderness of the whole uterine lining on exploration with the sound. The danger of acute endometritis lies in the possibility of its causing peritonitis or infection of the blood in cases where there is no proper granulation wall formed to prevent the entrance of fission

germs into the lymphatics and veins. Chronic endometritis may be a sequel of the acute condition. The treatment consists of rest in bed, emptying of the bowels, and application of ice-bags. In cases of septic endometritis, antiseptic uterine douches are used as mentioned in acute metritis, and the uterus is tamponaded with iodoform gauze of 20 per cent strength. When the fever and the foul discharge still continue, and there is no disease of the appendages, curetting comes into consideration. In acute gonorrhoeal endometritis this could only be permitted at the very commencement of the disease before it has reached the tubes and the peritoneum, when the uterus and appendages are not perceptibly tender on pressure. The gynecologist very rarely sees such cases.

Chronic Endometritis.

This disease arises from the same causes as chronic metritis, and in addition from mischief, usually of an infectious character, which reaches the endometrium from the vagina.

Gonorrhoeal and puerperal endometritis, and as B. S. Schultze has pointed, the endometritis of young girls, arise in this way. The humid tract of menstrual fluid at the time of menstruation offers an opportunity for infection from the atmosphere. In addition to this, direct irritants of the endometrium may produce inflammation. To this class belong the endometritis of myomata (Wyder), and the endometritis after abortion, which is caused by the retention of chorionic villi and decidual cells. Finally ovarian diseases can reflexly excite hyperæmia of the uterus, and lead to hyperplastic endometritis (Brennecke).

1. Endometritis Corporis Chronica.

Pathologico-anatomical Condition. On microscopical examination only the signs of inflammation are