Chapter II: The Peculiarities of Certain Accidental Acute and Chronic Diseases (2)

[Footnote 25: _The Change of Life_, 4th ed., p. 227, 1882.]

Incidentally, it may be remarked that gall-stones are apt to give origin to distressing symptoms during the menopause. The causes in operation are substantially the same as those already mentioned in connection with the functional disorders of the liver.

CLIMACTERIC NEUROSES.--Incidental mention has been made, in the discussion of the physiology of the menopause, of functional changes in the nervous system, as involved in the perspirations, flushes, hemorrhages, and other so-called critical discharges. Knowledge at the present time of the physiological changes undergone by the nervous system during the menopause is limited to these few general statements, all of which are not yet definitely established facts. The field has always been a fascinating one to the medical writer, probably because, in the utter absence of precise information, the widest play is given to the most vivid and fertile imagination. The literature of the subject abounds in vague terms, figurative expressions, and rhetorical forms. Numerous ingenious and interesting speculations may be found in the writings of systematic authors from Gardanne[26] to Barnes and Tilt.

[Footnote 26: _Aris aux Femmes entrant dans l'Âqe critique_, 1816.]

Tilt, following in the wake of the French writers, asserts that the nervous system is in a state of irritability or nervocism. This assertion conveys no information, as irritability may be the expression of weakness as well as of strength. The system is said to be in a condition of nervous plethora. We have seen that the rôle of plethora in recent pathology is insignificant. Cohnheim denies its existence altogether, except as a transitory state. Even admitting the existence of that state, what evidence is there that nerve-force accumulates in the body under the same conditions as the blood?

We have no desire to minify the importance of the physiological and pathological changes in the nervous system connected with the menopause. In comparison with these alterations the other phenomena of the menopause are insignificant. In the absence of precise knowledge, however, it is useless to devote time and attention to empty speculation.

In no part of the subject of climacteric neuroses are notions more obscure or information less precise than in connection with the diseases of the sympathetic or ganglionic nervous system. Under the term gangliapathy Tilt[27] has grouped a number of symptoms frequently observed during the menopause, which have their origin in a condition of "more or less debility associated with paralysis, hyperæsthesia, or dysæsthesia of the central ganglia of the sympathetic system." Gangliapathy includes the functional disorders described by other observers under the terms cardialgia, gastralgia, gastrodynia, and the like.

[Footnote 27: _The Change of Life_, 4th ed., p. 109, 1882.]

But it is impossible to view affections of the sympathetic apart from disorders of the general nervous system. It is impossible to distinguish {443} the conditions described by Tilt as ganglionic shock, paralysis, hyperæsthesia, and dysæsthesia from abdominal neuralgias and many of the functional and organic diseases of the abdominal viscera. Finally, the connection of these various disorders, entirely irrespective of names, with the change of life has never been demonstrated, nor even rendered in a high degree probable.

Cerebral Hyperæmia.--The older authors dwell with especial emphasis upon hyperæmia of the brain as an important functional disorder in connection with the change of life. The condition is supposed to be apt to occur, in the absence of perspirations, flushes, and the other so-called critical discharges, as the result of plethora. Headache, tinnitus aurium, dizziness, heaviness, drowsiness, suffusion of the face and neck, bounding pulse, are among the symptoms which have been referred to the lighter forms of cerebral hyperæmia. Few systematic writers, however, sustain Dusourd in his assertion that apoplexy and the severer forms of hyperæmia of the brain are frequently caused by the cessation of menstruation.

Under the impression that plethora actually caused cerebral hyperæmia and the symptoms mentioned, and doubtless influenced by the teachings of Broussais (1844), Tissot, Hufeland, and Meissner advocated bleeding in the treatment of climacteric neuroses. Fordyce Barker and Tilt may be mentioned among modern clinicians who retain the old opinion as to the nature and treatment of this condition.

Cohnheim,[28] representing the modern school of pathologists, says "that except as a transitory state polyæmia does not occur under any circumstances." In recent pathology the various appearances of plethora are regarded as caused chiefly by dilatations of the skin blood-vessels, and not by an increase in the total blood-mass. The changes in the character of the pulses are referred to alterations in the vessels or their innervation. Even admitting the existence of the so-called plethora universalis, it does not follow that headache, dizziness, tinnitus aurium, and the like are due to cerebral hyperæmia. Andral has well said that these symptoms might with equal justice be ascribed to qualitative changes in the constitution of the blood.

[Footnote 28: Pepper, _System of Medicine_, Vol. III. p. 886.]

Whatever view may be accepted as to the pathology of cerebral hyperæmia, and as to the necessary connection with the change of life, two important facts derived from experimental physiology deserve careful consideration before bleeding is performed for the relief of the symptoms mentioned:[29] (1) A high blood-pressure does not imply an augmentation of the total blood-mass. A large quantity of blood may be injected into the vessels without any considerable elevation of pressure. (2) Bleeding does not directly lower blood-pressure unless the quantity of blood removed be dangerously large.

[Footnote 29: M. Foster, _Physiology_.]

In the lighter cases the so-called derivative treatment fulfils all the indications. Hot, irritating foot-baths, purgatives, saline diuretics, are indicated for the relief of distressing symptoms. Diet, exercise, frequent bathing, and other hygienic resources exercise a most important prophylactic function.

Hysteria.--The occurrence of hysteria during the menopause, as at other periods of life, is a well-established fact. Whether or no there is {444} any direct pathological connection of cause and effect between the change of life and the disorder is a question which has been the subject of much controversy, and at the present time is unsettled. Gardanne, Dubois, D'Amiens, Vigaroux, and Beclard think the relation one of coincidence; Charcot, Tilt, F. Hoffman, Pujol, and Meissner are of the opinion that the climacteric may stand in a causal relation. Tilt's tabulated cases bearing upon this subject show nothing more than the coincidence of the two conditions, and contribute nothing to the solution of the problem. There are important considerations which favor the view that while the menopause may influence hysteria favorably or unfavorably, it is only in exceptional cases that the climacteric is the immediate cause of the affection. While hysteria may occur at any time of life, it is most frequently observed between the ages of fifteen and twenty years. It is in a high degree probable that a woman who has arrived at her forty-fifth year without hysterical manifestations will not be molested during the change of life. It is not an uncommon observation to see hysterical woman rapidly regaining health during the pre-cessation period, and making complete recoveries before the permanent resettlement of health.

Hysteria during the menopause does not differ as to symptoms from the affection at other periods of life. It retains its protean character. Almost all the described forms of nervous disease may be accurately simulated. The severer forms of the disorder are paroxysms characterized by convulsions, coma more or less complete, or delirium. Coma enters to a greater or less degree into the paroxysms characterized by convulsions. Lypothæmia--a term used by the older writers to signify an hysterical semi-unconsciousness with feeble pulse and widely-dilated pupils--is frequently observed. This condition, as well as a state termed pseudo-narcotism by Tilt, may be regarded as a lighter form of coma.

Functional paralyses and pareses of motion or sensation, or both, are occasionally observed. Paraplegia is of relatively frequent occurrence. Not infrequently this condition is of reflex origin, the eccentric irritant residing in the uterus and adnexa or the gastro-intestinal canal. Hemiplegia and general paralysis are observed less frequently.

In the differential diagnosis it is necessary to exclude epilepsy and eclampsia, although it is well to bear in mind the fact that both these conditions may coexist.

The treatment of climacteric hysteria differs in no essential particular from that of the same disorder at other periods of life. The practitioner, however, has the comfortable knowledge that with the resettlement of health all symptoms, in the absence of local disease, will probably disappear.

It may not be amiss, in passing, to notice the value as a palliative measure of that old and well-tried remedy, the hot-water enema containing asafoetida. One to two ounces of the tincture of asafoetida in one quart of hot water, carried well up into the colon, is usually productive of excellent results, moral and physical.

Climacteric Pseudocyesis.--False or spurious pregnancy is a neurosis of not infrequent occurrence at or about cessation. It may justly be regarded as one of the mimetic forms of hysteria. The symptoms which give origin to the illusion may be observed in young, unmarried women or long after the cessation of ovulation and menstruation. In {445} the large proportion of cases, however, the phenomenon is noticed at or about the climacteric. The subjective and objective signs of this curious condition may simulate pregnancy very closely. The breasts are swollen and tender, and a milky fluid may exude from the nipple. Nausea and vomiting in the morning and the various sympathetic disorders of pregnancy may be feigned. The abdomen may become enormously distended from the deposition of adipose tissue in the abdominal walls and omentum and the flatulent distension of the intestines. Foetal movements are simulated by intestinal peristalsis and irregular contractions of the abdominal muscles. The ensemble of symptoms may be very deceptive, as shown by the famous case of Joanna Southcott. Crichton Browne[30] relates the history of an illustrative case which came under his observation in the West Riding Asylum. A woman long past the menopause claimed to be two months advanced in pregnancy. At the end of seven months she informed her friends that she was about to be confined. Accordingly she went to bed, and the process of simulated parturition lasted four days, terminating with a bloody discharge from the vagina.

[Footnote 30: _British Medical Journal_, 1841.]

The differential diagnosis is easy. The mammary changes, upon close examination, will be found to differ from those of pregnancy. Inspection, palpation, percussion, and auscultation will disclose the fact that the woman is only big with fat and wind, as Barnes puts it. Anæsthesia will facilitate the examination. Bimanual examination usually reveals the characteristic senile changes in the uterus or a pathological enlargement differing essentially from the gravid organ.

The so-called phantom tumors sometimes observed during the menopause are closely analogous to spurious pregnancies.

Epilepsy.--Epilepsy is a relatively uncommon disorder during the menopause. The present state of our knowledge indicates that the climacteric cannot be regarded as a distinct cause of the disease in the absence of previous epileptic seizures or inherited predisposition. Out of 200 cases of epilepsy occurring during the climacteric, observed by Jewell of Chicago, not a single case could be traced by the most rigid analysis to the change of life. Considering the rôle the sympathetic nerve plays in the etiology of epilepsy, it would not seem improbable, on a priori grounds, that the disease should be aggravated at the menopause. Evidence derived from clinical observation, however, is entirely inadequate to settle this question.

Insanity.--Various opinions are held as to the relation between the menopause and insanity. Mania, monomania, dementia, and even idiocy, are among the forms of mental alienation which have been attributed to climacteric influences.

Monomania.--There is much probable evidence in support of the view that the change of life may stand in a direct causal relation to monomania. On the other hand, no proof exists sufficient to establish a necessary pathological connection between cessation and mania, dementia, or idiocy.

Gardanne, Dubois d'Amiens, and Chambon have called attention to the occurrence of melancholia and hypochondriasis at this period. This opinion is confirmed by the results of Battey's operation in the hands of Lawson Tait, Bantock, Thornton, and other operators of large {446} experience. In many of the cases of artificial induction of the menopause melancholia has been observed as a most distressing sequela. However, in connection with Battey's operation there are numerous and important considerations which must be carefully weighed in order to distinguish between a relation of cause and effect and mere coincidence. The number of women operated upon is now large, and some of the cases of melancholia following ovarian extirpation are probably examples of the return of a disease of earlier life or of the influence of heredity. Then, the fact of disqualification for maternal duties supplies in many cases an adequate psychological cause for more or less complete mental alienation. The important effects of chronic hepatic hyperæmia and the coexisting gastro-intestinal catarrh--conditions so frequently present at cessation--must not be forgotten when disorders of the intellect are referred to the cessation of the ovarian stimulus.

The positive diagnosis of climacteric melancholia and hypochondriasis is always difficult, frequently impossible. After the careful exclusion of all other possible causes, it may be assumed with a certain degree of probability that the intellectual disorder is due to the change of life.

The prognosis of climacteric melancholia and hypochondriasis is not necessarily unfavorable. In a large proportion of cases sanity returns with the re-establishment of health. The treatment, in the absence of a positive diagnosis, must be expectant. Effort must be addressed to the removal of any possible cause. Hygienic measures fulfil all the indications for treatment in the disorder when it is caused by the change of life. Opium and alcohol must be employed with extreme care in view of the great danger of the formation of obstinate habits.

Uncontrollable impulses and perversions of moral instincts are frequently observed during the climacterium, as at other periods of life. There is no reliable statistical evidence sufficient to establish a necessary pathological connection between cessation and uncontrollable peevishness, impulse to deceive, suicidal impulse, nymphomania, dipsomania, kleptomania, and the like. Nor is it possible to assert that these various disorders are of more frequent occurrence during the menopause than at other periods of life.

{447}

DISEASES OF THE PARENCHYMA OF THE UTERUS; METRITIS AND ENDOMETRITIS.

BY W. W. JAGGARD, A.M., M.D.

Acute Metritis.

The occurrence of an acute inflammation of the parenchyma of the non-gravid uterus has been denied by many systematic writers. Wenzel[1] says the condition is a figment of the imagination; Duparcque is sceptical; Klob[2] up to 1864 had never seen a case in which a positive diagnosis was possible. Emmet[3] writes in the last edition of his valuable book, "Inflammation of the uterine body never occurs except after parturition."

[Footnote 1: _Krankheiten des Uterus_, p. 42.]

[Footnote 2: _Pathol. Anatomie der Weibl. Sexualorgane_.]

[Footnote 3: _Gynæcology_, 1884, p. 31.]

Comparatively recent investigations, however, have established the fact of occurrence beyond doubt or question. While a relatively uncommon condition, many facts with reference to its causation, pathological anatomy, and clinical course are definitely known.

ETIOLOGY.--Disturbances in connection with menstruation play a rôle of great importance in the production of acute inflammation of the uterine parenchyma. The rapid cooling off of extensive areas of the skin surface, as in wetting the feet in cold water, severe exertion, or the cold-water vaginal douche, may transform the normal menstrual congestion into an acute inflammation. The retention of menstrual blood within the uterine cavity, the result of organic stenoses, flexions, or tumors, occasionally gives origin to acute septic metritis. The inflammatory process frequently extends from the endometrium to the muscular substance. Gonorrhoeal endometritis is of chief clinical significance in this connection. Duparcque's observations, confirmed in 1872 by Noeggerath, have recently attracted a great deal of attention. Säuger's statement at Magdeburg, that one-ninth of all gynæcological cases are of gonorrhoeal origin, created some surprise at the time. In the light of the recent investigations of Schroeder, Bumm,[4] Lomer,[5] Oppenheimer,[6] and others, it is not considered an exaggeration, although it is still unsettled whether or no the gonococcus of Neisser is the agent of infection.

[Footnote 4: _Arch. f. Gyn._, xxiii. 3.]

[Footnote 5: _Deutsch. Med. Wochenschrift_, 22d Oct., 1885.]

[Footnote 6: _Arch. f. Gyn._, xxv. 1.]

Under the heading of traumatism a great number and variety of etiological factors are included. Operations on the cervix, curetting the uterine cavity, and other minor gynæcological procedures, in the absence {448} of careful antisepsis, may cause traumatic inflammation in the vicinity of the wound, which may involve the entire organ. An ill-fitting pessary, especially the intra-uterine stem, cauterization of the cervix or endometrium with the solid stick of nitrate of silver, intra-uterine injections, the careless passage of the sound, inordinate sexual indulgence,--are all potential causes. Bloeschke[7] relates the history of a case in which a piece of straw penetrated the cervix of a peasant-woman working in the fields. An acute metritis was the result.

[Footnote 7: Säxinger, _Prager Vierteljahrschrift_, 1866, i. p. 130.]

Finally, acute inflammations of the muscularis may be lighted up in the vicinity of new growths, as in the case of carcinoma of the cervix or mural fibroids. Such inflammations, however, as remarked by Schroeder, possess only a secondary significance.

PATHOLOGICAL ANATOMY.--The uterus, of a bluish-red color, is enlarged, especially in its upper two-thirds, to the size of a goose's egg, and is thickened in its antero-posterior diameter. Its walls, filled with venous and arterial blood, are soft and succulent from the transudation of serum. The bundles of muscular fibres are swollen, and the inter-muscular tissue is infiltrated with white blood-corpuscles and a few pus-corpuscles. Extravasations of blood, sometimes larger, sometimes smaller, are usually observed in the connective tissue. These changes are most marked in the innermost layers, where there is a greater abundance of connective tissue, and the inflammatory process is propagated toward the periphery. The endometrium, pelvic peritoneum, and connective tissue are usually involved. The tubes and ovaries are less frequently affected except in the case of gonorrhoeal infection.

SYMPTOMS.--The attack is usually ushered in by a chill, followed by elevation of bodily temperature--a symptom which is apt to persist throughout the course of the disorder. Pain, referred to the lower portion of the abdomen and sacral region, is constant. The sensation may be dull, gnawing, or boring, like the pains in the first stage of labor or abortion, or sharp and lancinating. Tenderness on pressure, indicating involvement of the perimetrium, is marked. The pain is increased in intensity by standing, walking, coughing, straining at stool, or any act which causes an elevation of intra-abdominal pressure. Distressing symptoms arise in connection with the bladder and rectum. Urination is frequent and painful, while the secretion may contain blood. Griping pains are felt along the colon and rectum; the sensation of fulness or the presence of a foreign body excites a frequent or constant desire to defecate, and the act is accompanied with straining.

When acute metritis is caused by wetting the feet in cold water during the period, the menstrual flow may be suddenly arrested, to return after a variable interval. In very rare cases menstruation is permanently suppressed, and even atrophy of the uterus may result. In other cases profuse menorrhagia may occur. Not infrequently this copious hemorrhage is physiological, relieving as it does the congestion of the organ.

Various sympathetic disturbances, as nausea and even vomiting, are occasionally observed.

Acute metritis is frequently complicated by inflammation of the endometrium, pelvic peritoneum, and connective tissue. Under these circumstances the symptoms peculiar to inflammation of the muscular substance {449} are masked. Acute metritis may terminate (1) in resolution, with gradual resorption of the exudation and return of the organ to its normal relations. (2) New connective tissue may be formed, giving origin to induration of tissue and permanent increase in size--the chronic uterine infarct of Kiwisch. The acute inflammation has become chronic. While admitting the possibility of this mode of termination, A. Martin[8] is of the opinion that a causal nexus is only demonstrable in isolated cases. (3) A very rare mode of termination is suppuration and the formation of abscesses in the muscular tissue. In these cases it is necessary, as pointed out by A. Martin,[9] to exclude myomata, which have undergone suppuration in the process of retrograde metamorphosis.

[Footnote 8: _Pathologie und Therapie der Frauenkrankheiten_, 1885, p. 181.]

[Footnote 9: _Ibid._]

DIAGNOSIS.--The more or less sudden occurrence of a chill, fever, and localized pain and tenderness urgently indicates a careful examination of the pelvic viscera by bimanual palpation. The uterus is exquisitely painful upon the slightest touch, even in the absence of any exudate. The organ is enlarged, especially in its upper two-thirds, and thickened in its antero-posterior diameter. The uterus is softened, resembling in its consistence the organ in the early months of pregnancy. During the stage of active hyperæmia the secretions are diminished in amount; at a later period profuse leucorrhoea, especially in the absence of menorrhagia, is a prominent symptom. The diagnosis of abscess in the uterine walls is difficult, if not impossible, when the collection of pus is small. The gradual enlargement of the uterus, the presence of fluctuation, the indications of pointing, and the constitutional symptoms are usually sufficient to establish the diagnosis when the pus-cavity has attained a considerable size.

PROGNOSIS.--Under appropriate treatment the prognosis of acute metritis is not unfavorable. It must, however, always be guarded, as it will be governed to a great degree by the causation, clinical course, and complications. Acute metritis from wetting the feet in cold water during the period and the like usually terminates in resolution. It is necessary to bear in mind the fact that in rare cases the function of menstruation may be permanently arrested, and even atrophy of the uterus induced. In acute metritis from traumatism the danger of general sepsis constitutes the unfavorable prognostic element. In gonorrhoeal infection the tendency to involvement of the tubes and peritoneum is great; moreover, the condition is apt to recur. In all forms of the disorder the relation to chronic uterine infarct deserves consideration. Finally, death may result from the rupture of an abscess, located in the uterine walls, into the abdominal cavity.[10] Fortunately, these abscesses usually open into the uterine cavity, rectum, or through the abdominal parietes.

[Footnote 10: Scanzoni, _Krankh. d. Weibl. Sexualorg._, iv. Aufl. Bd. i., p. 203; Lados, _Gaz. médic. de Paris_, 1839, p. 605.]

TREATMENT.--In general terms, the treatment may be described as vigorously antiphlogistic.

Chrobak[11] has pointed out in a detailed manner the absolute necessity of the most rigid attention to antisepsis in all the minor as well as the major operative procedures in gynæcology. The prophylaxis, a subject {450} of vital importance, is limited, so far as the general practitioner is concerned, to the enforcement of absolute cleanliness in all manipulations of the female genito-urinary tract.

[Footnote 11: "Untersuchung. der Weibl. Genitalia und Allgem. gyn. Therapie," _Deutsche Chirurgie_, Lief. 54.]

Absolute rest in bed in the dorsal decubitus, with the pelvis elevated or depressed according to the patient's sensations, is a matter of primary importance. Pain demands for its relief the free use of morphine hypodermatically or opium per rectum. Chloral is a valuable adjuvant.

In the absence of menorrhagia free and repeated scarifications of the cervix are indicated to deplete the uterus. Twelve to twenty leeches applied to the abdomen above the symphysis will measurably relieve the congestion of the perimetrium. At a later stage, when the disorder does not occur at a menstrual epoch, mediate cold-water irrigation, by means of Leiter's modification of Petitgard's tubes, over the hypogastric region is an invaluable therapeutic resource. When the affection occurs during the period, hot compresses applied to the abdomen, hot sitz-baths, and even hot-water vaginal injections, are grateful.

The rectum and sigmoid flexure frequently require evacuation. A simple warm- or hot-water enema will usually secure this result. Occasionally a dose of castor oil is indicated, but drastic cathartics are distinctly contraindicated.

When the acute metritis is caused by traumatism, as in the case of operations on the cervix and curetting of the endometrium, the wounded surfaces demand attention. Under these conditions the neck of the uterus and the uterine cavity require careful antiseptic local treatment.

Abscesses in the uterine walls rarely indicate operative interference, except in case of pointing in the direction of the abdominal cavity. When incision is indicated the pus-cavity is usually large and superficial, and its evacuation involves no especial difficulty.

The treatment of the later stages of acute metritis will be considered in connection with the subject of Chronic Metritis.

Chronic Metritis.

SYNONYMS.--Chronic uterine infarct (Kiwisch); Diffuse connective-tissue hyperplasia of the entire uterus (Klob, C. Braun, Wedl); Induration of the uterus (Wenzel); Engorgement (Lisfranc); Hysteritis, Phlegmasie rouge (Duparcque); Congestion ou engorgement hypertrophique métrite (Becquerel); Interstitial metritis (De Sinéty); Congestive hypertrophy (Emmet); Areolar hyperplasia, Diffuse interstitial hypertrophy, Sclerosis uteri (Thomas, Skene); Subinvolution, Irritable uterus (Hodge).

In the absence of exact knowledge with reference to the ultimate pathology of so-called chronic metritis, it is impossible to frame a definition which cannot be justly criticised. Schroeder's definition answers all practical purposes, and probably contains as few objectionable terms as any other in the literature of the subject.

DEFINITION.--Hyperplasia of the connective tissue of the uterus combined with increased sensibility.

ETIOLOGY.--1. Subinvolution of the puerperal uterus is a frequent cause of chronic metritis. But the number of etiological factors which {451} interfere directly and indirectly with the retrograde metamorphosis of the puerperal uterus is immense. Getting up too early from childbed, inability to suckle the child, too early sexual intercourse, retention within the uterine cavity of blood-clots or placental remains, acute inflammations of the uterus during the puerperium, retroversions and flexions of the puerperal uterus, severe exertion and the like,--are some of the more usual causes in this connection. Involution of the puerperal uterus is effected by contractions of the muscular walls, fatty metamorphosis of the uterine substance, and profuse secretion. Disturbance of any one of these processes may defer indefinitely the return of the organ to its normal relations. When pregnancy is prematurely interrupted the operation of each of these factors is materially modified. Uterine contractions are relatively feeble. The stimulus of a nursing child is also lacking. The albuminoids of the muscular protoplasm are not so readily converted into fat capable of easy resorption. A comparatively large quantity of decidua vera--even in the absence of portions of the foetal envelopes--is retained within the uterine cavity, and the secretory activity of the endometrium is seriously disturbed. Then, women are less careful after miscarriages than labor at term.

Laceration of the cervix uteri--an accident liable to occur in abortion as well as during confinement at term--if at all extensive, usually interferes with the retrograde metamorphosis of the uterus.

2. Continuous or repeated hyperæmia, active or passive, frequently exceeds physiological limits and leads to chronic metritis. Menstrual subinvolution, dysmenorrhoea from organic stenoses, flexions, changes in position with retained menstrual fluid, excessive venery, masturbation, conjugal onanism, chronic endometritis--especially gonorrhoeal--inflammations of the pelvic cellular tissue, chronic oöphoritis, new formations as in the case of carcinoma and myoma,--result in the production of active flexion and venous engorgement. The pernicious effects of conjugal onanism in the causation of chronic uterine infarct have been dwelt upon with particular fondness by Wenzel, Scanzoni, Emmet, Goodell, and numerous other ancient and modern gynæcologists of distinction. Van de Warker,[12] on the other hand, is of the decided opinion that the operation of this etiological factor has been exaggerated. His conclusions are based upon an incomplete gynæcological study of the Oneida Community. Onanism was practised on a colossal scale by this strange people for a number of years. Summing up the results of his imperfect investigations, Van de Warker says: "I can discover nothing but negative evidence relating to the effect of male continence upon the health of the community." It is quite possible that too much importance has also been attached to excessive venery. Fritsch[13] does not stand alone when he says, "I have examined puellæ publicæ for years, but have not gained the impression that metritis chronica is of frequent occurrence."

[Footnote 12: Ely Van de Warker, "A Gynecological Study of the Oneida Community," _The American Journal of Obstetrics, etc._, August, 1884.]

[Footnote 13: Heinrich Fritsch, _Die Lageveränderungen und die Entzündungen der Gebärmutter_, 1885, p. 318.]

3. Venous stasis from organic hepatic, cardiac, and pulmonary diseases doubtless predisposes to chronic inflammation of the metrium. {452} Constipation, usually habitual with invalids, and an over-distended bladder, are causes which are more frequently and directly operative in the production of vascular engorgement and displacements of the uterus.

4. Various operative procedures upon the cervix, ill-advised and frequently repeated intra-uterine applications, must be included in the list of causative agencies.

5. Chronic metritis is one mode of termination of acute inflammation of the uterine parenchyma. This method of origin, however, is seldom observed except after repeated attacks of acute inflammation, as in the case of gonorrhoeal infection.

The enumeration of possible causes might be indefinitely prolonged. Scanzoni's classical monograph on chronic metritis contains a much larger number. As remarked by Fritsch,[14] "In the elastic bands of his conception of the disease every catarrh, every affection of the uterus, fitted finally snugly into place." The more common efficient causes have been indicated.

[Footnote 14: _Op. cit._, p. 299.]

PATHOLOGICAL ANATOMY.--Modern pathological doctrines on chronic metritis are largely modifications of the opinions so ably advocated by Scanzoni[15] in 1863. Scanzoni, while fully recognizing the various forms of chronic uterine infarct, simplified the study of the subject by comprehending them all under two stages: I. the stage of infiltration; II. the stage of induration.

[Footnote 15: _Die Chronische Metritis_, Wien, 1863.]

I. In the first stage the uterine tissue is infiltrated with serum, blood, and fibrin (serös-blutige, serös-faserstoffige Infiltration). The organ is in a state of engorgement oedema, the consequence of active and passive hyperæmia. It is enlarged in volume, altered in shape, reddened and more or less sensitive on pressure, soft and doughy to the sense of touch. The uterus may remain in this condition, or, after a longer or shorter interval, pass over into the stage of induration. Long-continued venous hyperæmia leads with comparative infrequency to induration, although intercurrent inflammations, exudations, and new formations of tissue may produce that effect. This stage cannot be invariably viewed as of an inflammatory character. These enlargements of the uterus are frequently examples of the nutritive disturbances commonly observed in other organs in consequence of long-continued venous hyperæmia. The close correspondence of Scanzoni's stage of infiltration with Emmet's congestive hypertrophy is at once apparent.

II. In the stage of induration a luxuriant growth of connective tissue replaces the specific tissue-elements which are destroyed by a chronic inflammatory process. Early in this stage there may be an actual increase in size of the individual muscular elements. Ultimately, the hypertrophy disappears, the soft and succulent connective tissue becomes fibrillated, and the vessels are narrowed, sometimes obliterated, by its contraction. The uterus, though still enlarged and altered in shape, is of a pale color, anæmic, dry, tough, and hard. Ultimately, the uterus is reduced in size by the cicatricial contraction of the firm, fibrillar connective tissue. On section the tissue is white, of cartilaginous consistence, and the knife creaks as it divides the structures. Scanzoni's stage of induration is thus nearly identical with the areolar hyperplasia, diffuse interstitial hypertrophy, sclerosis uteri, of Thomas and Skene.

{453} Klob[16] a pupil of Rokitansky's, attributes the hyperplasia of connective tissue to nutritive disturbances, considers the terms chronic metritis and chronic infarct anatomically incorrect, and classes the condition among the new formations. Carl Braun[17] and Wedl in 1864 assumed the same position.

[Footnote 16: Jul. M. Klob, _Pathologische Anatomie d. Weibl. Sexualorgane_, Wien, 1864.]

[Footnote 17: _Lehrbuch d. g. Gynaekologie_, Wien, 1881, p. 351.]

Klebs[18] is of the opinion that, although the so-called chronic uterine infarct may be of inflammatory origin, in the majority of cases the clinical and anatomical demonstration is lacking. With Scanzoni and Virchow, he distinguishes two forms of the disease, the one consisting in hyperplasia of the muscular elements, the other in a similar change in the connective tissue.

[Footnote 18: _Handbuch der Pathologischen Anatomie_, Berlin, 1873, iv. p. 878.]

Birch-Hirschfeld[19] supports the doctrine of Scanzoni, that the stage of induration at least is of an inflammatory nature. The connective tissue is formed out of emigrated white blood-corpuscles. Hypertrophy of the muscular elements is also observed in certain cases.

[Footnote 19: _Pathologische Anatomie_, p. 1131.]

Fritsch[20] has materially strengthened the position of Scanzoni by his recent anatomical investigations. Mayrhofer[21] substantially reproduces Scanzoni's doctrines.

[Footnote 20: _Op. cit._, p. 309 _et seq._, Stuttgart, 1885.]

[Footnote 21: _Entwicklungsfehler und Entzündungen des Uterus_.]

Finally, the great majority of modern clinicians have accepted Scanzoni's teachings as originally uttered or as modified in non-essential details. Schroeder,[22] De Sinéty,[23] and A. Martin[24] are notable examples of the truth of this statement.

[Footnote 22: Carl Schroeder, _Handbuch der Krankheiten d. Weibl. Geschlechtsorgane_, Leipzig, 1881, p. 91.]

[Footnote 23: L. de Sinéty, _Manuel practique de Gynécologie et des Maladies des Femmes_, Paris, 1879.]

[Footnote 24: _Op. cit._, Wien, 1885, p. 185.]

The hyperplasia of the connective tissue may be diffuse or circumscribed. It may be limited in development to the collum or corpus uteri. The perimetrium is usually thickened, and other signs of chronic inflammation of that structure are usually present. Chronic endometritis is a constant accompaniment. The pelvic connective tissue is not commonly involved. The plexus pampiniformes and utero-vaginales frequently undergo varicose dilatation.

SYMPTOMS.--The onset of the disease is so insidious and protracted that it is difficult to determine the exact order of occurrence of the symptoms in point of time. Then the complications are so numerous and important that the symptoms of the chronic metritis are frequently masked. A sensation of weight, fulness, or pressure within the pelvis may direct the patient's attention to her condition. This sensation may increase to such a degree that the woman complains of heavy, dull, dragging pains, referred to the centre of the pelvis or the sacral region. Backache is a constant and distressing symptom. Pains radiating up over the abdominal parietes and down the thighs are frequently experienced. Coitus may be productive of acute distress. When the uterus is anteverted, pressing against the bladder, ischuria is the usual result. Constipation, usually present as one of the etiological factors, is aggravated by the retroversion or retroflexion of the top-heavy uterus. Under these {454} circumstances one or both ovaries may be drawn down along with the prolapsed, retroverted uterus, and add materially to the woman's discomfort. The act of defecation is painful; the woman avoids the water-closet, days and even weeks elapsing between evacuations.

Disturbances of the menstrual function are constant. All forms of dysmenorrhoea, including dysmenorrhoea membranacea, are liable to occur. Menstruation is usually profuse, giving origin to menorrhagia, which usually results in the production of an alarming degree of anæmia. The periods are irregular in recurrence and duration. The periodic discharge of blood may last from one to three weeks, and then cease, to reappear after a variable interval of from six to eight weeks. In other cases menstruation may last the usual length of time, but recur every two or three weeks. Amenorrhoea may be observed in the stage of induration.

Priestly,[25] Fasbender,[26] Fehling, and numerous other clinicians have called attention to intermenstrual pain (règles surnuméraires) as a tolerably constant symptom of chronic metritis. From fourteen to fifteen days after and before the regular time for menstruation vague intrapelvic pains are complained of, and the woman is of the opinion that the monthly flow of blood is about to begin. The pains, however, are not so severe, and do not last so long, as those of menstruation. Occasionally bloody mucus may escape from the vagina. Fehling ascribes this intermenstrual pain to the swelling of the mucous membrane preparatory to the next monthly discharge of blood. The symptom is not at all pathognomonic, as it occurs in connection with oöphoritis and other pathological conditions.

[Footnote 25: _Brit. Med. Journ._, 1872, p. 431.]

[Footnote 26: _Zeitschrift f. Gebürtskulfe und Frauenkrankheiten_, i. 1.]

As the result of the chronic endometritis, which usually follows parenchymatous inflammation, metrorrhagia is frequently observed. Leucorrhoea, more or less profuse, is a constant symptom. Opinions vary extremely as to the systemic reaction following chronic metritis. General failure of nutrition, functional disturbances of the gastro-intestinal canal, hysteria, headache,[27] facial neuralgia (Barnes), coccygodynia, vaginodynia, skin diseases, alopecia (Hebra), and a host of other affections, have been ascribed from time to time to the direct influence of chronic uterine infarct. Doubtless, the condition under discussion plays an important rôle in the production of these and other disorders. But the position is utterly untenable at the present day that chronic parenchymatous inflammation of the uterus is the efficient cause in the absence of all other etiological factors.[28]

[Footnote 27: Peaselee, "Uterine Headache," _American Medical Monthly_, 1860.]

[Footnote 28: Fritsch, _op. cit._, 1885, p. 323.]

Intercostal neuralgia and mastodynia, with swelling of the breasts and darkening of the areolæ, are phenomena of such constant occurrence in connection with chronic uterine infarct that a direct causal nexus is in a high degree probable. The investigations of Krause[29] have established the fact of anastomotic communication between the arteries supplying the mammary gland and those distributed to the uterus. The perforating branches of the internal mammary artery supply in part the mammary gland. The superior epigastric artery, one of the terminal branches of {455} the internal mammary, anastomoses with the inferior epigastric, which arises from the external iliac a few lines above Poupart's ligament. The inferior epigastric sends off a spermatic branch which passes along the round ligament and anastomoses with the ovarian artery derived from the aorta, and the uterine artery derived from the anterior trunk of the internal iliac. The nervous communication is effected through the sympathetic and spinal nerves. There is nothing remarkable, therefore, in the occurrence of intercostal neuralgia, mastodynia, and nutritive disturbances in the mammary gland as the result of chronic parenchymatous inflammation of the uterus. The intercostal neuralgia and mastodynia are examples of reflected neuroses the result of compression of nerve-fibres by the infiltration or of an ascending neuritis (Fritsch).

[Footnote 29: _Specielle und Makroskopische Anatomie_, Hannover, 1879.]

PHYSICAL SIGNS OF CHRONIC METRITIS.--Bimanual palpation prior to the stage of cicatricial contraction reveals alterations in size, shape, position, consistence, and sensibility of the uterus. Variations in size are extreme. Veit[30] has recorded a case in which the fundus extended two inches above the umbilicus. The uterus is usually thickened, especially in its antero-posterior diameter. As regards position, the organ may be prolapsed, elevated, or remain in situ. The consistence will depend upon the stage of the disease. During the stage of infiltration the organ is soft and imparts a doughy sensation to the examining finger. During an exacerbation of acute inflammation the vagina is hot and dry; the uterus is swollen with blood and very sensitive on pressure. During the intervals between exacerbations no change in sensibility is noticed. The sound demonstrates a varying degree of elongation of the uterine cavity. During the second stage, after cicatricial contraction of the connective-tissue elements, the uterus is relatively small, hard, and insensible.

[Footnote 30: _Frauenkrankheiten_, 2 Aufl. p. 367.]

The cervix is hard or soft according to the time of examination. In virgins or women who have not borne children enlargement is of relatively infrequent occurrence. In multiparæ, especially in cases of bilateral cervical laceration, the increase in volume is great. The mucous membrane of the cervical canal is everted and studded with minute cysts--distended follicles.

The influence of chronic metritis upon conception is not direct. When the endometrium is not seriously involved the condition seems to exercise no untoward influence. However, associated with chronic uterine infarct as complications we have endometritis, salpingitis, oöphoritis, perimetritis, and displacements, pathological states which may obviously cause sterility.

When conception does occur, abortion follows with relative frequency. The reason why is not clear. The chronic endometritis may interfere with the development of the decidua; the parenchyma may not be able to undergo evolution. When pregnancy reaches its normal termination, labor is not materially influenced by the pathological condition of the uterus, but complications are liable to occur during the puerperium. Postpartum hemorrhages which do not readily yield to ergot are observed as the result of the deficiency in muscular elements. The hyperplasia of the connective-tissue elements and destruction of the muscular tissue is a distinct predisposing cause of complete or incomplete uterine inversion. {456} Subinvolution is increased. Menstruation recurs soon after pregnancy, and the chronic metritis is aggravated.[31]

[Footnote 31: A. Martin, _op. cit._, Wien, 1885, p. 189.]

Occasionally, gestation, parturition, the puerperium, and lactation seem to exercise a favorable influence on the state of the parenchyma. In exceptional cases all traces of the original chronic metritis disappear with the puerperium. The connective-tissue hyperplasia may undergo the same involution to which the hypertrophied muscular tissue is subject. This favorable termination of the disease is seldom observed during the stage of induration.

TERMINATIONS.--I. Chronic metritis may terminate during the stage of infiltration in resolution. This mode of termination is rare. It is observed occasionally as the result of involution in the puerperal uterus. Judicious treatment in favorable cases may reduce the size of the uterus and relieve all distressing symptoms. Recidiva of the disease are liable to occur, however, and all traces of the former condition seldom disappear.

II. Usually, the condition persists, with acute exacerbations, through years, until cessation of menstruation and ovulation occurs. Under the influence of the change of life the symptoms may gradually disappear and the uterus may undergo senile atrophy. In some cases chronic uterine infarct seems to defer the climacteric changes. Finally, the disease may continue after the menopause, usually with abatement in the severity of the symptoms.

III. The morbid condition may terminate in induration. The uterus becomes comparatively small, hard, and insensible. Amenorrhoea may be the result. This process may be viewed as a relative cure, since it is attended, as a rule, with amelioration of all the troublesome symptoms.

DIFFERENTIAL DIAGNOSIS.--It is not always an easy matter to institute a differential diagnosis between chronic metritis and pregnancy and fibroid tumors by bimanual palpation. Alterations in the volume, form, position, consistence, and sensibility of the uterus occur in pregnancy as in chronic metritis. But in pregnancy the uterus, particularly in its vaginal portion, is softer; the organ is not so sensitive; the cyanotic hue of the vaginal mucous membrane is more marked; arterial pulsations in the vagina are more evident; the uterus enlarges more rapidly; finally, there is the history of the case. Pregnancy may occur, however, in a chronically inflamed uterus, and this fact must be borne in mind.

The alterations in the size of the uterus are usually circumscribed in fibroid tumors. One wall is thickened; the other retains its normal relations. In submucous fibroids the cervix is shortened; in chronic metritis it is usually enlarged. In both submucous and interstitial fibroids the cavity of the uterus is encroached upon--a fact to be determined by the use of the sound. The history of the case will throw some light upon the differential diagnosis. Frequently, however, it is impossible to exclude fibroids by any of the means already mentioned. Dilatation of the cervix, and the careful examination of the walls by the finger introduced into the uterine cavity, will clear up the diagnosis in the most obscure case.

PROGNOSIS.--The prognosis with reference to life is favorable. The duration of life however, may be abbreviated in exceptional cases by {457} disturbances of nutrition, anæmia the result of menorrhagia and metrorrhagia, extension of the inflammation to the peritoneum, and the like--conditions which predispose to some intercurrent affection.

Although the immediate danger of death is minimal, the woman is rendered wretched by the frequent exacerbations of acute inflammation and other symptoms already mentioned. The spontaneous disappearance of the affection with the puerperium or menopause is of such seldom occurrence as to have but slight bearing on the general rule.

Under judicious treatment disappearance of the more distressing symptoms may be confidently expected during the stage of infiltration. The outlook is especially favorable in cases of puerperal subinvolution in the absence of chronic inflammations of the endometrium and parametrium. A perfect restitution of the uterus to its normal condition is so seldom effected by any rational therapy that for practical purposes this desirable result may be excluded from consideration. Recidiva of the disease are liable to occur at any time.

TREATMENT.--Prophylaxis.--Very much can be done to prevent the occurrence of chronic metritis. A careful consideration of the etiology of the disease will at once suggest the principles of prophylactic treatment. The conduct of the second stage of labor, the puerperium, lactation, the hygiene of menstruation, are subjects especially significant in this connection. Antecedent acute metritis and endometritis under a rational therapy usually terminate in resolution, and their pernicious influences as etiological factors may be avoided, or at least modified, in the large majority of cases. The early rectification of uterine flexions and displacement is urgently indicated in view of the probable consequences.

Uncomplicated chronic metritis is such a rare affection that efforts at curative treatment are seldom addressed to the condition of the parenchyma, to the exclusion of the endometrium, perimetrium, and parametrium. Certain special indications, however, exist in the case of chronic uterine infarct, and the discussion of treatment is limited here to their consideration.

1. Local Treatment.--In view of the pathology of the condition, local treatment, especially in the first stage, is antiphlogistic.

Hot-Water Vaginal Douche.--The irrigation of the vagina with hot water, of different degrees of temperature according to the indications in the concrete case, deservedly occupies the high position in American gynæcological therapeutics which Emmet[32] in particular has assigned it. The smooth muscular fibres of the uterus are excited to contract, and the whole pelvic circulation is directly or indirectly influenced. During the stage of infiltration--Emmet's congestive hypertrophy--hot-water vaginal irrigation is simply an invaluable adjuvant. But to secure the maximum benefit from this remedy it must be rationally employed. With reference to posture, Emmet recommends the dorsal decubitus, with elevation of the hips, or, better, the genu-pectoral position. The temperature of the water should be rapidly elevated from blood-heat to 110° F., or to as high a degree as the patient can tolerate. The quantity of water will vary with the stage of the treatment and the improvement in health of the patient. It is customary to begin the irrigations with one to two {458} gallons of water, and to increase or decrease the quantity according to circumstances. Two irrigations per diem--one at night before going to bed, one in the morning upon rising--are usually sufficient. Fritsch[33] has tried on an extensive scale the plan of continuous vaginal irrigation with hot water through five and even ten hours, but has obtained better results with the simple periodic vaginal douche as recommended by Emmet.

[Footnote 32: _Principles and Practice of Gynæcology_, 3d ed. 1884, pp. 85, 113.]

[Footnote 33: _Op. cit._, 1885, p. 337.]

During the stage of induration, when the muscular elements have been destroyed and replaced by connective tissue, the beneficial effects of the hot-water douche are decidedly less evident. Nor is the plan applicable to all cases during the stage of congestive hypertrophy. General nervous excitement, insomnia, and even positive intrapelvic pain, sometimes, though rarely, may result. The range of therapeutic application of the hot-water vaginal douche is largely empirical.

Local Depletion.--The local bloodletting of from a drachm to one ounce of the fluid, repeated according to the indications every three or four days, ranks next to the hot-water vaginal douche in importance as an antiphlogistic agent. This plan of treatment is of especial value as an adjuvant during the stage of infiltration in cases of menorrhagia, metrorrhagia, exacerbations of acute inflammation, and the like. Local depletion, however, is a double-edged sword. It may cause an increased determination of blood to the uterus and aggravate the pathological condition already existing. This effect is observed when the bloodletting is practised at too short intervals.[34] Thus, frequent scarifications of the cervix constitute a most important therapeutic resource in the treatment of certain forms of atrophy of the uterus.

[Footnote 34: A. Martin, _op. cit._, 1885, p. 59.]

Local depletion of the cervix is effected by scarification, puncture, leeches, wet and dry cupping. Scarification and puncture have almost entirely superseded the other two methods.

Local depletion has fallen into a state of comparative disuse in America. In the Woman's Hospital of New York[35] it has almost completely passed out of vogue. In Germany, however, it constitutes the basis of all methods of treatment. Schroeder, A. Martin of Berlin, H. Fritsch of Breslau, Carl Braun, Spaeth, and Chrobals of Vienna unite in enthusiastic advocacy of its intelligent employment in suitable cases.

[Footnote 35: T. Gaillard Thomas, _Diseases of Women_, 5th ed., 1880, p. 334.]

Glycerin Tamponade.--Sims many years ago called attention to the employment of cotton tampons saturated with glycerin in the treatment of chronic metritis and kindred affections. In virtue of its avidity for water the glycerin tampon, when placed in the vagina, provokes a profuse aqueous discharge. The albuminoid constituents of the blood are not affected, while the capillaries are drained of their aqueous elements. Emmet[36] has substituted oakum for absorbent cotton. Oakum, when saturated with glycerin, becomes soft as a sponge, is perfectly antiseptic, and will remain odorless in the vagina a much longer time than cotton. Glycerin dissolves the salts more readily than water. Boric acid (1:10), potassium iodide (5:100), iodoform, chloral, and a variety of substances may be applied locally by means of this menstruum. Glycerin, employed in conjunction with hot-water vaginal irrigation and scarification, or used {459} alone in cases contraindicating these procedures, is an important addition to our therapeutic resources.

[Footnote 36: _Gynæcology_, 1884, p. 128.]

Local Alteratives.--Much importance is attached in the United States to the application of various alteratives to the vaginal portion and endometrium in cases of chronic uterine infarct. They may accomplish good results indirectly--for example, by curing the accompanying endometritis--but it is doubtful whether they have any direct effect in hastening the resorption of the infiltration.

The vaginal vault and intravaginal portion of the cervix are usually painted with the compound tincture of iodine; mercury, potassium iodide, iodoform, and other substances are introduced into the vagina by means of vaseline, gelatin, and cacao butter.

Operative Treatment.--1. Repair of Lacerations of the Cervix.--The importance of the repair of lacerations of the cervix for the cure of chronic uterine infarct and allied conditions was recognized by Emmet in 1862. In the autumn of 1862 he devised and performed the operation, which is now known the world over as Emmet's operation. This highly original and valuable surgical procedure has been but little modified in the years which have intervened since its first full description in 1869.

2. Amputation of the Collum Uteri.--Carl Braun[37] and Wedl in 1864 pointed out the fact that amputation of the neck of the chronically inflamed uterus is frequently followed by a more or less complete involution of the whole organ, resembling very closely the reductive metamorphosis of the puerperal uterus. August Martin in recent years has called attention to Braun's observation, and at the Naturforscherversammlung in Cassel described a series of seventy cases in which amputation of the collum uteri had been performed for the relief of chronic metritis. As an ultimate resort in extreme cases, amputation of the neck of the uterus is now a generally well-recognized operative procedure.[38]

[Footnote 37: _Wiener Med. Jahrbücher_, Wien, 1864.]

[Footnote 38: H. Fritsch, _op. cit._, 1885, p. 343.]

3. Castration.--At a comparatively recent date a determined effort has been made to include desperate cases of chronic metritis under the indications for the performance of oöphorectomy. Numerous and distinguished surgeons have taken this advanced position. But at the present time the cases in which the operation has been performed are too few in number and too recent to warrant positive deductions with reference to the effects of the operation.

2. General Treatment.--It is not possible to adequately discuss the subject of the general or constitutional treatment of chronic metritis in the limited space at our command. It is scarcely necessary to add that the subject is of vital importance, and more frequently neglected than the local treatment. The indications for therapeutic aid are usually apparent, and are not always peculiar to the condition. Attention has been directed, in other portions of this work, to the importance of the observation of hygienic laws, in the widest sense of that expression, with respect to diet, rest, clothing, recreation, personal cleanliness, temperance in sexual intercourse, and other bodily habits.

Habitual constipation, involving as it does engorgement of the portal system and pelvic veins, demands especial consideration. In the absence of regular daily alvine dejections the most elaborate plan of local and {460} constitutional treatment will fail to effect amelioration of symptoms. Diet, exercise, and the like are not sufficient, as a rule, to correct this most obstinate habit. Among remedial agents, senna, rhubarb, cascara sagrada, and the milder laxatives deserve particular mention. The compound licorice powder and confection of senna of the U. S. Pharmacopoeia are comparatively innocent in their effects, even when used through long periods of time. Aloes must be employed with a certain amount of caution. As pointed out by August Martin,[39] when there is a disposition to uterine hemorrhages the drug, in the exercise of its well-known influence on the pelvic circulation, may increase this tendency. Clysters may be employed to advantage in connection with hygienic and medical means.

[Footnote 39: _Op. cit._, p. 195.]