passive congestion. In cases where there is a distinct laceration of the cervix, and specially where the catarrhal patches can be made to disappear by rolling the lips inwards on each other, Emmet's operation is indicated. Local depletion by scarification or leeches was formerly much employed, but is going out; its effects are only transitory. Scarification is done best through the Fergusson speculum, and with a lancet shaped bistoury; a number of small punctures are made, from a quarter to half-an-inch in depth. Leeches are applied as follows:-Fergusson's speculum is passed; a pledget of lint, with string attached, is placed in the cervical canal to prevent their crawling upwards into the uterine cavity; a little blood is drawn by superficial scratches and three or four leeches thrown into the speculum, and pushed up towards the cervix

Schroeder's excision of the cervical mucous membrane in cervical catarrh. Fig. 184 line of incision in mucous membrane. Fig. 185 mucous membrane excised and flap be. turned in on ab. (Schroeder).

with a pledget of cotton wadding. We must watch the speculum lest the leeches slip out; after the speculum and leeches are removed, the vagina is douched with a tepid injection of carbolised water.

Scarification is, however, useful for another object. When there are hard knobby retention cysts producing irritation by the pressure of their contents, the puncturing of these diminishes the chronic imflammation. When these cysts project as small polypi, they are easily snipped off.

In very chronic cases, the only remedy is the destruction of the diseased glandular tissue—just as in tonsilitis we excise the tonsils. This has been done by the application of strong nitric acid or the cautery; but the use of the curette or knife is a much more effective and safe method than any process of cauterisation. Thomas commends the steel curette for the removal of the diseased glands; it is applied 'so forcibly as to remove the arbor vitæ and mucous glands from the os internum

to the os externum. Sometimes a second operation in two or three weeks after the first has been necessary, and sometimes even a third.' Schroder uses the knife, and operates as follows. The cervix is laid hold of with two volsella, one on each lip, and drawn downwards. It is divided laterally as far as the fornix with the scissors, so as to form an anterior and a posterior lip which are separate as far as the vaginal roof (fig. 184). A transverse incision (seen in section, at a, in fig. 185) is made across the base of the anterior lip, dividing the whole thickness of the cervical mucous membrane. He next pierces the point of the lip at c, pushing the knife in the direction bb till it reaches the cross incision a; he carries the blade outwards first to one side and then to the other, so that all outside of the line a b c is cut away. The flap of cervix is now turned in, and stitched as in fig. 185. The advantage claimed for this method of operating is that the degenerated cervical mucous membrane is replaced by vaginal mucous membrane which shows no tendency to degenerate. Schroeder has operated thus more than three hundred and fifty times (two deaths), and with very good results as to the cure of the catarrh.

CHAPTER XXIX.

ENDOMETRITIS.

LITERATURE.

Atthill-On Endometritis: Dublin Jour. of Med. Sc., Jan., 1873.

Barnes-Op. cit., p 530. Braun Carl-Therapie der Metritis und Endometritis, etc. Wiener med. Wochenschrift, 1873, Nos. 39-43. De Sinéty-Gynecologie, p. 327: Paris, 1879. Guérin-De la Métrite aigue: Annales de Gynecolog., Juillet, 1874; and Arch. de Tocologie, July 1877. Hennig-Der Katarrh der inneren weiblichen Geschlechtstheile: Leipsig, 1862. Klob-Op. cit. S. 211. Olshausen-Ueber chronische hyperplasirende Endometritis des Corpus Uteri: Archiv. f. Gynäkologie, Band. VIII., Heft 1. Playfair-Intra-uterine Medication: Brit. Med. Jour., December 1869; ibid, March, 1880; Lancet, January and February, 1873. Récamier-Union Méd. de Paris, 1850, 1-8 Juin. Routh-On "Fundal Endometritis: " Obst. Trans., Vol. XII. Cases of Menorrhagia treated by injections, etc.: Obst. Trans., Vol. II. Schroeder-Op. cit., S. 108. Simpson, Sir J. Y.-Op. cit., p. 736. Smith Tyler— Pathology and Treatment of Leucorrhoea: London, 1855. Thomas-Op. cit., p. 268.

INFLAMMATORY action may affect the peritoneal covering, the muscular substance, or the mucous membrane of the uterus, producing perimetritis, metritis, or endometritis. Usually we find more than one of these conditions present at once, as the inflammatory action is rarely limited to one of these coats. Perimetritis is only a part of pelvic peritonitis, under which head it has already been considered.

We now consider inflammation limited to the mucous membrane of the uterus-endometritis, which may be acute or chronic.

DEFINITION.-Inflammation of the mucous membrane of the uterus. SYNONYMS.-Uterine catarrh, internal metritis.

PATHOLOGY.

In acute endometritis both body and cervix are involved, and usually the underlying muscular coat also. The mucous membrane is swollen and soft, and covered with red stained mucus or creamy pus. Extravasations of blood are present as red streaks or patches. These changes are not so marked in the cervical mucous membrane as

in that of the body; the vaginal portion has the same appearance as during pregnancy, being soft and swollen and showing round the os red catarrhal patches.

The ciliated epithelium is destroyed, and sometimes casts of the epithelium of the glands are found in the discharge (Schroeder). The secretion is at first serous, then purulent.

In chronic endometritis, the mucous membrane is hypertrophied and marked with patches of old extravasation.

The microscopic appearances vary with the structures which are principally affected. Our knowledge upon this subject is principally derived from the examination of the portion of mucous membrane removed by the curette. We can distinguish three pathological types according to the tissue chiefly involved. In the first, the glands are hypertrophied; in the second, the vessels are dilated and enlarged; in the third, an

Cross section of a granulation in a case of Endometritis P. 1. Stroma; 2. dilated glands (de Sinéty). undifferentiated embryonic tissue is produced. We must remember, however, that in no case is one structure alone affected; there is no hard and fast line between the different processes. For the following description we are indebted to the researches of Olshausen, Carl Ruge, and de Sinéty.

According to Schroeder's clinical observations, the microscopic investigation of which has been made by Ruge, the most frequent condition is a hypertrophy of the glands. In some cases they are so much hypertrophied that the granulations appear as masses of glandular tissue, as is well shown by the accompanying figure from De Sinéty (186). In such a condition, the chief symptom is leucorrhoea.

Olshausen has described very carefully the changes of the mucous membrane in cases of the second type, in which the only symptom is hæmorrhage. The mucous membrane is hypertrophied to three or four times its normal thickness. It is elevated through its whole extent in a

soft cushion-like swelling, or in more localised spongy masses; the hypertrophy does not extend beyond the os internum to the cervix and thus resembles in its situation a decidual membrane. The portions removed by the curette are unusually thick; one side presents a smooth rose

coloured surface which resembles the appearance of the mucous membrane of the intestine, and the other has a deep-red raw-surface. "The microscopic examination of these scrapings," Olshausen says, "shows that there is great hypertrophy of the mucous membrane with increase

Cross section of granulation composed of dilated vessels in a case of endometritis 4. 1. Vessels cut longitudinally; 2. vessels cut transversely; 3. dilated vessel filled with blood corpuscles; 4. embryonic tissue (de Sinéty).

of all its elements-moderate dilatation of the lumina of the glands, enlargement of the blood-vessels, and marked cellular infiltration of the connective tissue" (fig. 187). The characteristics of this type are, that the glands do not become enlarged so as to produce cystic dilatations, and that the blood-vessels are greatly distended; the latter fact explains the

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