SENILE INTERNAL METRITIS.

In most women, the cessation of menstruation extinguishes the inflammatory affections of the womb; in some, however, it increases the congestion of its body, checking the flow, which often gives it relief. In most of these cases, while the body of the womb becomes the seat of morbid activity, its neck becomes atrophied, so as to impede, more or less, the free exit of the fluids contained in the cavity of the womb. The result of this is, that the uterus becomes more and more distended by a sero-sanguinolent, a mucosanguinolent, or a muco-purulent fluid. Severe uterine pains, of an expulsive character, repeatedly occur, till at last the fluid is ejected, and the patient recovers. This form of disease has been called the uterine leucorrhea of old women by my friend Dr. Duncan of Edinburgh.

If, while the mucous membrane of the body of the womb remains in a low state of inflammation, its neck becomes obliterated by physiological atrophy, or by the pressure of a tumour determining adhesive inflammation of the cervical canal, there will be a collection of fluid in the distended body of the womb; such cases have been described as hydrometra. The occurrence may be attended by no pain, and may be only detected after death; or, on the contrary, it may cause forcing pains and pelvic fulness, as in the case of a woman of fifty-seven, mentioned by Scanzoni, whose womb was sufficiently distended to rise about two inches above the pubis. By astringent injections, and the use of nitrate of silver, the pains subsided, and the womb diminished to the level of the pubis. It may, however, occur either from the thinning of the uterine walls, or from excessive accumulation of fluid, that the womb will burst, as in a case recorded by Duparque, where, ten years after the cessation of menstruation, the womb burst, in a paroxysm of pain, and caused death on the following day. A large quantity of blood was found in the peritoneum, which came from a rent in the fundus, the neck being cartilaginous, and its canal obliterated. Without asserting that all these cases are the result of inflammation, doubtless many are like that in which Dr. Duncan found the uterine cavity so dilated, that it might

contain little less than half an ounce. The walls of the uterus were abnormally thin and soft, and the mucous membrane of the uterine cavity had an irregular and almost ragged surface, the depressions being apparently seats of ulceration.

The body of the womb is generally felt to be enlarged in senile internal metritis, and if it be possible to pass the uterine sound into its cavity, the manner in which its extremity may be freely moved about, shows that its cavity is unusually capacious. The discharge varies, being mucous, viscid, or purulent, and it is unusually offensive from the length of time it has sojourned in the womb. There is sickness in

addition to the pains I have described.

Having thus briefly sketched what is known relative to cervical catarrh and internal metritis, it may be well to state some of the points in which they differ, as the last complaint has but little occupied the profession of this country. Cervical catarrh is very frequent; internal metritis is rare. Cervical catarrh is as often observed in the single as in the married; internal metritis seems to affect more frequently those who have borne children. In cervical catarrh the discharge is viscous; in internal metritis, serous or sanguineous, and very abundant. Cervical catarrh gives rise to no abnormal growths; internal metritis generally does. In cervical catarrh life is never compromised; it is not unfrequently so in internal metritis. Intra-uterine injections have been found useless and often dangerous in cervical catarrh, but are sometimes serviceable in internal metritis.

CHAPTER XXII.

TREATMENT OF INTERNAL METRITIS.

"IN chronic diseases, the whole man is entirely altered in his nature, and therefore to cure him one must place the whole man into the crucible." So says Sydenham, and in some of the cases that have been related, despaired-of health was recovered by a protracted residence in a new abode, or by emigrating to another country, and although this is seldom possible, we must advise the attempt to improve the patient's constitution by a long residence at Kreusnach and other German spas, or at least by removing her from her usual home, if it be the focus of ever-recurring vexations. The menstrual periods cannot be watched with too much care, the patient being always then confined to her room, or to her bed. With regard to special therapeutical measures, I have little to say that is not known by well-informed practitioners, but I believe that, if mercury is too often given in many kinds of diseases, it is frequently too timidly administered in rare cases, wherein it might effectually cure the patient. It is certainly justifiable to give mercury to salivation in severe intractable cases of internal metritis, and it will often be found difficult to salivate the patient. Blisters, croton oil, antimonial ointment, a silk thread seton, or an issue, may be applied successively to the abdomen above the pubis, and if the neck of the womb be sound, it may be even advisable to try the effect of potassa fusa c. calce, applied to it as an issue. Two Turkish baths a week gave great relief to one patient, and others have derived benefit from hydropathic appliances. There are certain general indications of treatment available in all cases, whether the uterine mucous membrane does, or does not present organic products on its surface. Thus it is necessary to ascertain by a careful

examination, whether the hemorrhage does not depend upon a polypus or an erectile development at the orifice of the neck of the womb. The menorrhagia must be restrained by the means usually recommended, among which I may mention the horizontal position in a cool temperature; the application of cloths steeped in cold vinegar and water to the pubis and to the inner part of the thighs; the injection of cold water, or cold aluminated water, to the vagina and rectum, two or three times in the course of the day. Such measures will often suffice, and they may be associated with the internal exhibition of ergot of rye, in doses of from five to ten grains three or four times a day, from which I think that some benefit is to be derived, though in many cases the practitioner will be obliged to ring the changes on mineral acids, acetate of lead, tannin, gallic acid, &c., according to the rules laid down in works on therapeutics, to which I refer the reader. The patient's strength must be kept up by such an amount of food as can be digested; but it should be taken cold. Wine and stimulants should be avoided, and all drinks should be as cold as possible. Water, or cream ices, flavoured according to the patient's taste, may be advantageously given between meals. Should the complaint determine continued insomnia and hysterical symptoms, acetate of morphine should be given, and the doses progressively increased until such symptoms abate. In one interesting case previously related, the patient for many days took from two to three grains of acetate of morphine, and I believe that it not only brought on sleep and diminished hysterical phenomena, but was also instrumental in curing the uterine disease, for the manifest improvement only set in when the patient was brought under its influence.

There are indications of local treatment which apply to all varieties of internal metritis

1. To cure all disease of the neck of the womb, and thereby attempt the cure of its body.

2. To freely dilate the neck of the womb, to prevent internal metritis being kept up by the distension of the cavity of the womb from accumulated fluids, and also to enable its neck to bear without injury the passing of half-organized blood-clots and voluminous decidual membranes.

3. To attack the disease in its stronghold by the surgical treatment of the inner cavity of the womb, if life be menaced.

1. With regard to the first indication, I have often pointed out its obvious utility, and I need not recapitulate the various modes of treatment that may be required. In cases of chronic metritis the patients are too much reduced by loss of blood, want of exercise, and constant pain, for bleeding to be admissible, but I hold leeching the womb in great esteem, and it may be necessary to repeat the application of five or six leeches several times in succession, before or after the menstrual period; but when the neck of the womb is very sensitive, swollen, red, and giving a soft spongy sensation to the finger, I have found that leeching the womb sometimes gave an amount of pain that can scarcely be described, and caused a loss of blood very detrimental to the patient's strength. When such is the case, I now apply the leeches to the vagina, and with very good results.

2. The dilatation of the neck of the womb may be useful in all the varieties of internal metritis ; in the metrorrhagic, as a means of preventing the distension of the womb, and of facilitating the discovery of the condition of the internal mucous membrane by means of the curette; in the purulent and the senile variety, dilatation has enabled me to abate the pains by which the expulsion of pus would be otherwise attended. Dilatation is equally useful in the exfoliative variety. Even when it does not seem to be absolutely required, I have dilated the womb, with the view of accustoming its neck to allow the passage of a foreign body without too much pain, and feel confident that I have thus given great relief. Except in rare cases, it is only necessary to use moderate sized sponge tents to obtain all the advantages to be derived from dilatation.

3. "Diseases that nature cannot cure may be cured by hygiene and remedies, and if not by these, by fire and steel." This teaching of Hippocrates is fully applicable to the treatment of internal metritis, and in a comparatively small number of desperate cases it is necessary to try severe surgical measures, which should be always prefaced by the previous full dilatation of the neck of the womb. This is particularly necessary