The latter is of great importance for the treatment following. A second application of caustic should not take place until the eschar has sloughed off.

After cauterization the cold compresses should be continued.— When after 24 hours it becomes evident that the cutis is foldy, the swelling has decreased, the eschar sloughed off, treatment may proceed with the same or a stronger solution (2%) or (10 gr. to 1 oz) followed by neutralization. No complications of the cornea should change this plan of treatment.

The nature and extent of the diseases of the cornea are such that their discussion would require more time than has been at my disposal though they may be referred to on some future occasion.

ARTICLE XII.

PERIMETRITIS AND PARAMETRITIS.

BY DR. F. B. ROBINSON, OF GRAND RAPIDS.

Whenever any disease is designated by a large number of names it may be first noted that the disease is common, and second that the precise nature of the disease is unsettled. It shows that it has been investigated by different persons and in different ages of progress. This is true of the disease known as Perimetritis and Parametritis and the strife of settlement still progresses. It has been recognized under a variety of names as periuterine phlegmon, subperitoneal inflammation, pelvi-peritonitis, pelvi-cellulitis, periuterine cellulitis and inflammation of the uterine appendages. The terms Peri-metritis and Para-metritis were first suggested by Virchow and first introduced into medical writings by Matthews Duncan. The old Romans recognized the disease but it was afterwards forgotten for centuries until some 75 years ago when physicians began to study it in general The definitions and terms applied to the disease are so various that one cannot accept them until the definition is known. This paper will define Peri-metritis as inflammation of the cellular or connective tissue and the peritoneum immediately surrounding the uterus. The definition given to Para-metritis will be an inflammation of the connective tissue between the ligamenta lata and of the peritoneum forming the ligaments. The last sentence will undoubtedly receive criticism but none will be more gratified than we if the criticism elicits a better term. The difficulty in settling the nature of the disease lies in the idea as to what is the particular tissue attacked by the inflammation or whether it attacks more than one kind of tissue at a time; e. g., does the inflammation attack the peritoneum or the cellular pelvic tissue first and if so which? The question cannot be settled on the living patient and pathology is not absolutely decisive. However, it seems almost impossible to have inflammation of

the pelvic cellular or connective tissue without inflammation of the peritoneum and vice versa.

SYMPTOMS.

A physician is called to a woman, in most cases from one week to several months, after labor or abortion. The patient has had a chill. She suffers from pain in the small of the back and it radiates down the limbs and up the body, it is dragging in character. She generally has painful urination and constipation from spasms in the intestines. Temperature will range from 102° to 1050. She cannot walk. She is thirsty, flushed and her facial expression is characteristic of abdominal pain. She reports that she has caught cold. Generally leucorrhoea is active and tinged with blood. That is likely endometritis and especially should no sound, caustics or ferric astringents be applied to the uterus as acute peritonitis and even death has resulted from such action. A digital examination in such a case is required. The clean index finger well oiled is carefully introduced into the vagina while the other hand is lightly placed on the abdo. men. It may be stated that the more delicately and gently the examination is made the more knowledge of the parts and conditions is acquired because rough examination causes voluntary and involuntary spasms preventing full exploration. The bimanual manipulation aids the educated finger to pick up sensations which enable the examiner to judge of the conditions in the pelvis. In the first place all the organs of the pelvis will likely be found to be tender. If it be a fresh case a soft, yielding boggy tumor will be felt beside or behind the uterus. The pelvic organs which should be movable are found partially or totally fixed. The contents of a tumor may be blood (hæmatocele), serous fluid, pus or fibrous. Fluid tumors should be examined very gently as we know of two cases of death a few hours after the examination by rupture into the peritoneum. Whatever this tumor is it interferes with surrounding organs. The vagina, uterus, tubes, ovaries and even intestines may be displaced or entangled in the inflammation. Inspection shows the vagina swollen and congested. The uterus is enlarged and blue with congested venous blood. The Nabothian follicles often swollen like small blisters which being pricked will exude a serous fluid. Blood and mucus can be seen flowing from the cervix showing that endometritis exists. The secretions continually flowing will soon cause erosions on the os and vaginitis.

PATHOLOGY.

The Pathology may be considered as one of the most important parts of the subject with reference to a correct understanding of the disease and also because it is this new formation that the physician must attempt to displace. The successful removal of the exudate makes a healthy woman and indicates a doctor's usefulness. The opportunity offered in the Vienna dead house and dissecting rooms, to see post mortems on women who have had Perimetritis and Parametritis is very great. The abdominal and pelvic organs can be observed in all conditions from the slightest exudate to the consolidation of the genital and most of the abdominal viscera into a single

mass.

The products of the Perimetritic and Parametritic inflammation are serous fluid, lymph, fibrine and pus. Its location is subperitoneal, intraperitoneal or both. The infectious forms contain micro-organisms. The pathological stages are congestion, exudation and suppuration, Fortunately suppuration is relatively rare with infectious origin. The royal road for the infectious origin of Perimetritis and Parametritis is through the veins and lymphatics of the uterus and the fallopian tubes, starting nearly always from the endometrium. A puerperal uterus will sometimes show all these tracts full of purulent material. One case that we observed showed that the infection had gone through one fallopian tube, and infecting a place on the peritoneum as large as a twenty-five cent piece, caused death. However, the infection may enter through any lesion in the genital tract. For example one woman was fatally infected by the prick of an unclean needle in the vagina. The results of the exudate are dislocation, compression and fixation of organs. The dislocation of the ovary from the fallopian tube causes sterility. The fimbria of the tube cannot grasp the ovary to deliver a Graafian follicle to the uterus and its fixation in such a position dooms the tube and ovary to worse than uselessness. The exudate if large, compresses the organs and may cause partial or complete stenosis. The fallopian tube may be found compressed or bent at such an acute angle that its canal is virtually occluded; ova cannot pass. The rectum may be compressed causing constipation and painful defecation; the bladder also may be compressed or drawn into such condition as to cause cystitis, painful and frequent urination; a very serious amount of

pain and reflex disturbance may arise from the pressure of the exudate on nerves and plexes. In short all the abdominal and genital organs may become so entangled in the adherent mass that the eye can scarcely observe the border of healthy and diseased tissue. The compression on the sympathetic causes reflex cerebral symptoms, vomiting, hysteria, etc. The exudate may or may not all be reabsorbed and it may be left in various forms among the genital organs or intestines. Various false bands form from the exudate called pseudomembranes. These newly formed bands contract in healing and displace, compress and irritate the organs concerned. The pseudomembranes in contracting often succeed in encapsulating some of the exudate be it fluid or pus. This may remain encapsulated for a long time or perforate, or be absorbed. The attacked parts are much thickened by the chronic inflammation. The peritoneum, tubes and bladder can become very thick especially if the inflammation be of gonorrhoeal form when also the lymphatics are much enlarged. If the exudate suppurate it will perforate in the direction of least resistant tissue. The roads of perforation taken in order are the rectum, vagina, externally, bladder and peritoneum. The seat of the exudate has much to do with the location of perforation. The perforation in the vagina is the most favorable.

ÆTIOLOGY.

The causes of Perimetritis and Parametritis are various as shown by the different opinions of different authors. Emmet thinks that their origin lies in the veins of the pelvic cellular tissue and therefore would seem to be of the opinion that the disease could primarily arise in this tissue. Matthews Duncan thinks that the most prolific cause is endometritis, others attribute the cause to the tubes or ovaries. Thomas, more cautious and correct, mainly agrees with Duncan, states that two-thirds are due to parturition and abortion while the other third is due to a variety of causes. Notwithstanding any contrary statements we believe that Perimetritis and Parametritis are almost always secondary diseases. Scarcely a vestige of experience as to their primary origin in the pelvic connective has been gained in the examination of nearly fifteen hundred women. They occur mostly on the left side. This is probably due to the movements of the rectum, changing its caliber so frequently as to keep up an irritation. The same idea would be gained from the fact that it mostly