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 sievelike 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, extramenstrual 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 likedirect 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 gastrointestinal 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:1

I. The washing out of the uterine cavity;

II. The cauterization of the uterine cavity;

III. The curettement of the uterine mucous membrane.

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 endo metrium. Bandl's canule 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 circum

stances, 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.

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

VOL. IV.-30

ABORTION.

BY GEORGE J. ENGELMANN, M. D.

DEFINITION.-Abortion, the mishap of popular parlance, the fausse couche of the French, is the premature interruption of intra-uterine pregnancy, the expulsion of the non-viable ovum, whether the result of natural causes or criminal interference.

SYNONYMS.-Common as the accident unfortunately is, the nomenclature, both popular and scientific, is somewhat indistinct, the terms abortion and miscarriage being used in a variety of ways, so that the physician is liable to be misunderstood by his professional brethren and in danger of causing serious offence to his patients. A strict definition of the terms is hence of importance, and in order not to add to the confusion we can do no better than adopt the one now adhered to by the authorities of the day. Abortion and miscarriage are strictly synonymous, notwithstanding the popular belief that the term abortion is restricted to the criminal interruption of pregnancy, whilst miscarriage is supposed to designate the accident resulting from natural causes. Again, some make a difference in time between abortion and miscarriage-abortion being the expulsion of the ovum in the first four months of pregnancy; miscarriage, or the partus immaturus, in the next three months, from the fourth to the seventh; and the partus prematurus from the seventh to the ninth month. CLASSIFICATION.-We might, indeed, in regard to importance, cause, and course of expulsion, designate four different periods of gestationthe first two during the continuance of the chorion frondosum, and the last two during the period of placental development: the first during the first two months of pregnancy, before sufficient adhesions have formed; the second, still during the period of the chorion frondosum, until it begins to disappear, from the second to the fourth month; the third, in the early stages of placental development, before the term of foetal viability, from the fourth to the seventh month; and the fourth, which is everywhere recognized as the partus prematurus-premature delivery-from the seventh to the ninth month, when the placenta is fully developed with firm adhesions and the child viable.

For practical reasons and simplicity's sake we will distinguish only between abortion and premature labor-miscarriage, abortion, abortus, being the expulsion of a non-viable foetus, of the ovum before the time of complete placental development, in the first seven months of pregnancy; and premature labor, the interruption of pregnancy in the last two months, from the seventh to the ninth, when the foetus is viable and