Reprinted from 
Annals of Gynecology and Pediatry, 
June, 1892. 
Endometritis—Considered Clinically. 
BY CHARLES P. NOBLE, M.D. Endometritis—Considered Clinically.1 
CHARLES P. NOBLE, M.D. 
It is a healthful sign of the times 
that more attention is being paid in 
medical societies to the nature and 
treatment of endometritis. Endome- 
tritis is especially important in the 
category of diseases of women, be- 
cause, almost without exception, it 
forms one stage in the progressive in- 
flammatory or septic processes which 
eventuate in salpingitis, ovaritis and 
peritonitis. Therefore the curative 
treatment, or, better, the prevention, 
of endometritis constitutes a very 
large part of the prophylaxis of pel- 
vic inflammation in women. If endo- 
metritis could be prevented, or could 
be cured early, before the inflamma- 
tion has spread to the tubes, it is no 
exaggeration to say that the number 
of sick women would be reduced one- 
third, and the number of those seri- 
ously sick would be reduced two- 
thirds. Surely, this is an object to 
insure the careful attention and efforts 
of every one who treats the diseases 
of women ! Modern abdominal sur- 
gery offers every facility for the cure 
of the morbid conditions resulting 
from pelvic inflammation, and the 
methods of work have been so per- 
fected that but little progress can be 
anticipated along the same lines. 
Progress in the future, I feel sure, lies 
in the field of preventive medicine, 
and, happily, the inflammatory dis- 
eases of women are clearly prevent- 
able. 
VARIETIES OF ENDOMETRITIS. 
Three varieties of endometritis can 
be distinguished, clinically: gonor- 
rhoeal, septic, and simple. 
The status of gonorrhoeal and post- 
1 Read before the Obstetrical Society of Philadel- 
phia, May 5, 1892. 2 
CHARLES P. NOBLE. 
puerperal septic endometritis is so 
well defined that I shall make no com- 
ments upon them further than to say 
that in my experience the chronic en- 
dometritis which results from gonor- 
rhoea is apt to be suppurative, while 
that resulting from puerperal sepsis 
is apt to be haemorrhagic. Gonor- 
rhoeal endometritis, also, is much more 
difficult to cure, and extends more 
commonly to both Fallopian tubes. 
What I have called simple endome- 
tritis, for want of a better name, is 
not so easy to define. There can be 
no doubt, however, that virgins at 
times have endometritis, and that 
endocervicitis is not uncommon 
among them. It would be easy for 
me to adduce numerous illustrative 
cases. What the nature of the infec- 
tion is in these cases is usually ob- 
scure. Undoubtedly it is due at times 
to the exanthemata. Bacteriological 
studies in these cases will be of in- 
terest. 
CHRONIC CONGESTION OF THE UTERUS. 
Whatever will cause congestion of 
the pelvis will bring about turgescence 
of the vessels of the uterus and endo- 
metrium, and induce hypersecretion 
from the endometrium, constituting 
uterine leucorrhoea. Among other 
causes may be mentioned constipa- 
tion, sluggish portal circulation, fee- 
ble heart, pelvic tumors, etc. This 
condition of uterine congestion simu- 
lates endometritis, but is to be strictly 
differentiated from it, because treat- 
ment should be directed, not to the 
uterus, but to the morbid condition 
producing pelvic congestion. 
It is reasonable to suppose that 
chronic congestion of the uterus is a 
predisposing cause of endometritis, 
and that it acts by lessening the re* 
sistance of the endometrium to the 
attacks of germs present in the va- 
gina. . For example, it is well known 
that marked endometritis is a frequent 
concomitant of uterine fibroids; and 
this relation is too constant to be 
purely accidental. 
RELATIONS OF ENDOMETRITIS TO 
CHRONIC PELVIC INFLAMMATION. 
What is most to iie feared in endo- 
metritis is that the inflammatory 
process will extend to the uterine ap- 
pendages and peritonaeum. Unques- 
tionably, salpingitis and peritonitis 
are caused in this way almost without 
exception. The existence of salpin- 
gitis and peritonitis argues the pre- 
existence of endometritis. The ex- 
ceptions occur in tubercular, and in 
post-puerperal cases. The rule holds 
good in the post-puerperal cases, 
but exceptionally puerperal perito- 
nitis occurs without involvement of 
the tubes. I am aware that this 
statement will not meet with univer- 
sal acceptance, but I have seen and 
operated upon women having, and 
having had, puerperal peritonitis in 
whom the tubes were healthy. The 
inflammation spread through the 
uterus to the peritonaeum, or spread 
alongthe pelvic lymphatics and caused 
puerperal cellulitis with peritonitis. 
This fact explains why, in post-puer- 
peral cases, recovery at times takes 
place after apparently serious salpingo- 
peritonitis. Such cases often get per- 
fectly well, and the explanation is 
that the tube is not involved. These 
facts have a decided practical bearing 
on the questions of treatment in post- 
puerperal pelvic peritonitis. 
Not only is it true that endometri- ENDOMETRITIS—CONSIDERED CLINICALLY. 
3 
tis is the cause of salpingitis and per- 
itonitis, but it is also true that the 
pelvic congestion induced by these 
conditions, in turn, tends to aggravate 
the endometritis and prevent its cure. 
SYMPTOMS. 
Chronic endometritis is not ac- 
companied usually by marked symp- 
toms, other than those of leucorrhoea 
or uterine haemorrhage. I have de- 
voted special attention to this point 
in the study of cases and have found, 
when the endometritis is uncompli- 
cated, that pelvic or reflex pains are 
not complained of. When subinvolu- 
tion or metritis is present, pelvic dis- 
comfort is, at times, a symptom ; but, 
in my experience, the pelvic pain, sup- 
posed to be due to endometritis, is 
almost always due to diseased uterine 
appendages, and the supposed reflex 
pains have had a more reasonable ex- 
planation as being neuralgia, due to 
co-existing anaemia. I wish to lay 
special stress upon the paucity of 
symptoms of uncomplicated endome- 
tritis, because of late the electricians 
have been teaching very curious doc- 
trines concerning this matter, greatly 
exaggerating the local and constitu- 
tional symptoms of the disease. 
FREQUENTLY. 
Chronic endometritis is a very 
common disease, but in my expe- 
rience it is almost always compli- 
cated by salpingitis. This great 
tendency of the disease to spread to 
the tubes is the reason why it is im- 
portant to institute curative treatment 
in the early stages. Some time ago 
I looked through my case-book and 
found that four per cent, only were 
cases of uncomplicated chronic endo- 
metritis. 
TREATMENT, DILATATION AND 
CURETTING. 
The fact that endometritis is due 
to infection requires that treatment 
should have as its object the de- 
struction of the invading germs, and 
the removal of the results of the in- 
fection (the hypertrophied or hyper- 
plastic mucous membrane), or that it 
assists the efforts of the tissues them- 
selves in accomplishing these objects. 
I believe that these objects are best 
secured by dilatation and thorough 
curetting of the uterus under rigid 
antisepsis, together with subsequent 
applications of pure carbolic acid, or 
Churchill’s tincture of iodine, to the 
endometrium. This line of treatment 
is the more requisite as the morbid 
state of the endometrium is the more 
marked. And in very chronic or well- 
marked cases, in which there is great 
thickening of the endometrium, with 
general involvement of the glands of 
the corpus or cervix, it may be neces- 
sary to repeat the process. In this 
connection I wish to emphasize the 
fact that this treatment is advised 
only for cases of uncomplicated en- 
dometritis. In the treatment of cases 
of uterine congestion, due to pelvic 
tumors, or to chronic pelvic inflam- 
mation, or to various morbid states 
of the general economy, it can do no 
good. In the treatment of cases of 
endometritis, complicated by salpin- 
gitis or pelvic peritonitis, this method 
of treatment is absolutely contra-in- 
dicated, because of its futility and 
because of its liability to induce acute 
salpingitis and peritonitis. In my 
judgment, the necessity for careful 
diagnosis in these cases cannot be 
too strongly insisted upon, in order 
that uncomplicated cases of endome- 
tritis may be separated from compli- CHARLES P. NOBLE. 
4 
cated cases. In the one, dilatation 
and curetting, when properly done, 
is curative and safe; in the other, 
the procedure is futile and dangerous. 
The grounds on which this method 
of treatment is advocated for well- 
marked cases of endometritis are sev- 
eral. First, experience. All who em- 
ploy this treatment claim good results 
from it, and hold that it is safe, when 
properly done, in uncomplicated cases. 
Second, logic. In chronic endometri- 
tis the endometrium is infected and 
is thickened by inflammation. By 
using the curette vigorously most of 
the diseased membrane can be re- 
moved, and the occluded glandular 
ducts be opened, without entailing 
the formation of cicatricial tissue, 
owing to the peculiar anatomy of the 
membrane- And third, antisepsis 
and drainage are favored. Owing to 
the multitude of glands in the endo- 
metrium, it is probably impossible to 
disinfect it, hence antiseptic meas- 
ures should be directed rather toward 
aiding the tissues (phogocytes) in 
their battle against the germs than 
toward active disinfection. Applica- 
tions of tincture of iodine, or pure 
carbolic acid, after curetting, probably 
aid in disinfecting, the endometrium, 
but I think that their utility depends 
rather upon their mild caustic action. 
Drainage, which is secured by dic- 
tating the cervix, is a distinct gain, as 
preventing the retention of the dis- 
charges. 
Opposition to this method of treat- 
ment comes only from two sources. 
Certain surgeons claim that the treat- 
ment causes pus tubes, but they 
fail to report evidence to support their 
claims. In order to prove their posi- 
tion cases must be adduced in which 
the tubes were healthy, but in which 
salpingitis developed immediately or 
shortly after dilatation and curetting 
done under anaesthesia and with rigid 
asepsis. So far as I know, this has 
not been done. The point that is 
lacking is, knowledge of the state of 
the tubes before curetting. In the 
absence of this knowledge it is more 
rational to suppose that salpingitis 
existed prior to the curetting, and 
that it was aggravated by- it. The 
electricians also oppose the curette, 
advocating instead the galvano-cau- 
terization of the endometrium. There 
is good reason to believe that galvano- 
cauterization will cure endometritis, 
but the treatment is tedious and 
painful, and there is a positive danger 
of causing atresia of the canal at times, 
and more frequently of blocking up 
the mouths of the utricular glands 
by the cauterizing process. 
Dilatation and curetting is an oper- 
ation which requires the same care to 
achieve good results which is given 
to other operations on the uterus. 
The patient’s bowels should be well 
cleared out, and her skin be put in 
good condition, by the bath. Anaes- 
thesia is indispensable; without it 
the vagina cannot be well scrubbed, 
nor can the operation proper be thor- 
oughly done. The vagina should be 
carefully scrubbed with soap and 
water, then irrigated and douched with 
sublimate solution. The cervix is now 
exposed by means of the perineal 
retractor, seized with a bullet forceps, 
gently and moderarely dilated with 
Goodell’s dilators, and then the entire 
canal of the uterus is thoroughly cu- 
retted with the sharp curette. The 
debris is now washed away, an appli- 
cation of pure carbolic acid or of 
Churchill’s tr. iodine made, and the 
uterine cavity is lightly packed with ENDOMETRITIS—CONSIDERED CLINICALLY. 
5 
gauze. The gauze is removed the fol- 
lowing day, and serves to bring away 
any debris which has remained in the 
uterus. I have not used it to prevent 
haemorrhage, for I have had none, nor 
do I use it to dilate the uterus, for 
that has been done already. 
The patient should remain in bed 
at least three days, and be confined to 
her room for a week, being on simple 
food, and the bowels kept open. 
In my hands, cases of uncomplicated 
endometritis, treated in this way, have 
been cured, or much improved, and 
in no case has salpingitis been pro- 
duced. Such being the case I am un- 
able to comprehend the grounds on 
which the process is opposed, and am 
at a loss to understand how those who 
oppose the curette cure their cases of 
villous endometritis with metrorrha- 
gia, and their cases of endometritis, 
with well-marked glandular involve- 
ment with purulent discharge. 
GENERAL TREATMENT, 
both hygienic and medicinal, is of the 
highest importance in the cure of en- 
dometritis. Each patient should be 
carefully studied, proper hygienic di- 
rections given, and any special indica- 
tions met by appropriate remedies. 
Especially should the bowels be kept 
regular. 
VAGINAL MEDICATION, 
painting the vault of the vagina with 
Churchill’s tr. iodine, the use of the 
glycerine tampon, and the hot-water 
douche is always of value, and in mild 
cases will effect a cure. This treat- 
ment is especially effectual when the 
endometritis is kept up by pelvic con- 
gestion due to subinvolution following 
labor. Undoubtedly it is more effec- 
tual for the cure of pelvic congestion 
than for the cure of endometritis. The 
advantages are that it is perfectly safe 
and that it is painless. All cases in 
which there is a reasonable doubt con- 
cerning the existence of salpingitis 
should be treated by this method un- 
til the doubt is cleared up. Tender 
appendages, tender masses lateral to 
the uterus, are due at times to ovaritis 
and pelvic hyperaesthesia and not to 
salpingitis. Hence, in many cases the 
practical man will use this treatment 
until the diagnosis is completely made. 
It can do no harm, and does great 
good, especially by improving the pel- 
vic circulation. Its good effect in en- 
dometritis can be rationally explained 
only upon the supposition that by im- 
proving the circulation of the uterus 
it assists the tissues in bringing about 
an arrest of the inflammatory process. 
APPLICATIONS TO THE ENDOMETRIUM 
WITHOUT DILATATION 
should be divided into applications 
below the internal os and applications 
to the entire uterine canal. Non- 
caustic applications to the cervical 
canal are unobjectionable, and are 
indicated in mild cases of cervical 
endometritis. When the Nabothian 
follicles are markedly involved, the 
curette should be used. The value of 
applications to the entire uterine 
canal, except after the use of the dila 
tor and curette, is very questionable. 
The procedure is quite painful, and 
induces, at times, severe uterine colic. 
When the applicator is used, most of 
the medicament is squeezed out of 
the cotton in the cervix, so that but 
little reaches the body of the uterus. 
This method of treatment was much 
used twenty years ago, and the result 
of the experience of those using it was 
that it was ineffectual, painful and 
dangerous. (Thomas, Emmet, Good- 6 
CHARLES P. NOBLE. 
ell.) The accidents (peritonitis) en- 
countered, presumably, were due to 
the fact that complicated cases were 
treated. The peritonitis was ascribed 
to the entrance of fluid into the peri- 
tonaeum through the Fallopian tubes 
—sometimes forcibly injected by the 
syringe—sometimes driven into the 
tubes by the spasm of the uterus. 
More probably it was due to traction 
and manipulation of tubes containing 
septic material. It seems to me that 
the evidence upon these points is con- 
clusive, and that applications to the 
endometrium, through the undilated 
cervix, should be considered painful 
and futile. If the uterine syringe 
is used through the undilated cervix, 
there is positive danger of forcing the 
medicament into the tubes. Person- 
ally, I find no need for the uterine 
syringe under any circumstances, and 
feel that it should be consigned to the 
medical museum. For making appli- 
cations to the undilated uterine canal 
the experience of the past has shown 
it to be dangerous; and, for making 
applications to the dilated canal, it is 
not so useful as the cotton-wrapped 
applicator. The applicator can be 
made to come in contact with every 
point of the canal, and a thorough, 
and if necessary a prolonged, applica- 
tion of a medicament can be made; 
whereas, with the syringe the medi- 
cine is injected and immediately runs 
out, and it is largely a matter of chance 
as to what part of the uterine canal is 
treated. 
THE INTRAUTERINE GAUZE PACK 
has become a popular method of treat- 
ment of late years. This method is a 
development of the method of Vulliet 
of dilating the uterus by packing it 
with cotton tampons. It has been my 
practice always to tampon the uterus 
lightly with gauze after curetting. 
The gauze is removed the following 
clay and serves to bring away any 
debris which has remained in the 
uterus. I have had but little experi- 
ence with the prolonged and repeated 
use of the gauze pack, and hence speak 
of it with diffidence. In one case of 
gonorrhoeal endometritis, of three 
years’ standing, and with marked 
glandular involvement, which I cu- 
retted, I removed the gauze on the 
second day, replaced it, and removed 
it the second time on the fifth day. 
Somewhat to my surprise, when the 
gauze was removed, at least a half 
ounce of sanious mucus followed it. 
In this case it did not act as a drain, 
but as a hindrance to drainage. In 
the future I shall feel inclined to re- 
move the gauze daily. In office prac- 
tice, in cases seen after curetting, I 
have found it very painful to intro- 
duce the packing ; and it has occurred 
to me that the Philadelphia uterus is 
not as tolerant as that of New York, 
and of Continental Europe. 
As my experience grows, I feel 
more and more convinced that the 
fewer applications that are made to 
the endometrium above the internal 
os, in office practice, the better it is 
for the patients. 
P'or several weeks after dilatation 
and curetting, and in cases having a 
very patulous uterine canal, an excep- 
tion can be made. But as soon as the 
effect of the dilatation disappears it is 
best to recur to vaginal treatment, 
and if after a reasonable time recov- 
ery does not ensue, it is better to re- 
peat the process, rather than to per- 
sist with intrauterine applications. 
TREATMENT OF COMPLICATED CASES. 
In no disease are complications or ENDOMETRITIS—CONSIDERED CLINICALLY. 
7 
extensions of the disease more com- 
mon, and in the individual case com- 
plications must be recognized and the 
treatment varied to meet the indica- 
tions. Pelvic congestion, subinvolu- 
tion, metritis, displacement of the 
uterus, inflammation of the append- 
ages and peritonitis are the most 
common complications. The cause 
of the pelvic congestion must be 
sought for and appropriate treatment 
instituted, as diet and laxatives for 
constipation, exercise for sluggish 
portal circulation, strychnia and digi- 
talis for a feeble heart, and strychnia 
and small doses of ergot for atonic 
pelvic vessels. Subinvolution is best 
treated by the boroglyceride tampon 
and the hot douche locally, small 
doses of ergot, tonics and reconstruc- 
tives internally, together with grad- 
uated exercise out of doors. For 
metritis the same treatment is indi- 
cated, and, in addition, the local ab- 
straction of blood (two to four ounces 
weekly) and the repair of the cervix, 
if lacerated. Displacement of the 
uterus should be corrected. Where 
the tubes, ovaries and peritonaeum 
are involved the inflammation of these 
structures is the disease, and the en- 
dometritis is the complication. 
All operations upon the uterus and 
intrauterine applications are contra- 
indicated where salpingo-peritonitis 
exists. Pelvic local treatment should 
be restricted to vaginal applications. 
Whether the uterine appendages 
should be removed depends upon 
their condition. If adherent and per- 
sistingly painful, in spite of treat- 
ment, or if the tubes be occluded and 
retention cysts have formed, or if pus 
be present, the appendages should be 
removed. If, after recovery from the 
operation, the endometritis persists 
and causes distress, the uterus should 
be dilated, thoroughly curetted, and 
cauterized with saturated solution of 
chloride of zinc. As the function of 
the uterus is in abeyance it is imma- 
terial if its canal becomes obliterated. 
PROPHYLAXIS. 
From the nature of the pathogeny 
of the disease it follows that its pre- 
vention depends upon a strict per- 
sonal hygiene among women, es- 
pecially strict cleanliness of the geni- 
talia ; the early treatment of vaginitis 
when due to indifferent irritants or to 
accidental infection with germs, other 
than the gonococcus; and upon the 
prevention of gonorrhoea and of sep- 
sis in child-bed. 
CONCLUSIONS. 
Endometritis is due to infection. 
All causes of pelvic congestion act as 
predisposing causes of endometritis, 
and later tend to aggravate and per- 
petuate the disease. The rational 
treatment of endometritis consists in 
the employment of those agents which 
lessen pelvic congestion, which assist 
the tissues in combating the invading 
germs, and in getting rid of the re- 
sults of their activity. 
In typical cases of uncomplicated 
endometritis, dilatation and curetting 
of the uterus, under anaesthesia, and 
with full antisepsis, with subsequent 
applications of Churchill’s tincture of 
iodine, or pure carbolic acid, best ful- 
fill the indications. The general con- 
dition of each patient should be stud- 
ied, and each indication should be 
met by appropriate hygienic or med- 
icinal treatment. 
The use of the hot douche, paint- 
ing the vault of the vagina and the 
cervix with tincture of iodine, and the 
use of the glycerine tampon is valu- 8 
CHARLES P. NOBLE. 
able in all cases, and curative in mild 
cases. This plan of treatment should 
be employed always so long as there 
is any suspicion concerning the exist- 
tence of salpingitis. 
Intrauterine applications, by means 
of the cotton-wrapped applicator, are 
valuable and safe when the uterine 
canal is patulous, but are painful and 
of little value if that canal is con- 
stricted. Intrauterine medication 
should follow curetting, not precede 
it; and because of the pain it causes 
it should be employed only when 
strictly necessary. 
Careful, thorough diagnosis is very 
necessary. All complications should 
receive appropriate treatment. The 
most common complication—really, an 
extension of the disease—is inflam- 
mation of the uterine appendages. 
Where this exists, it is of such gravity 
that it should be considered the dis- 
ease, and the endometritis a complica- 
tion. During the existence of tubo- 
ovarian inflammation operations upon 
the uterus and intrauterine medica- 
tion are contraindicated. Should the 
uterine appendages be removed, and 
the endometritis persist, it should be 
treated by curetting and cauterization. 
In speaking of the induction of sepsis and 
extension to the uterine mucosa, with subse- 
quent involvement of the peritonaeum, I under- 
stood the author to say that this takes place, 
not infrequently, independently of the tube, as 
is shown by the fact that operation discloses 
the tube to be perfectly healthy. An experi- 
ence of my own a year ago has led me to 
believe that the tube may be the carrier of 
infection without itself being infected, that a 
patulous tube may be the canal through 
which the disease is carried to the peritonaeum 
and ovary, without itself undergoing inflam- 
matory action. A young woman was confined 
for the first time. The labor was easy, but 
three days later there was a considerable 
elevation of temperature. At the end of a 
week I was called to see the patient, in a 
neighboring city, to determine whether there 
was any involvement of the peritoneal cavity 
necessitating operation. Careful examination 
under an anaesthetic failed to disclose any 
evidence of involvement of the peritonaeum. I 
could not determine that the tubes and ovaries 
were affected. The uterus was dilated by the 
introduction of the finger, and there was at 
once an unpleasant odor perceptible. This 
had not been recognized before. Intrauterine 
injections had been employed from the time 
of the development of the elevation of tem- 
perature. The uterine cavity was curetted 
with the finger and a blunt curette, washed 
out with an antiseptic solution and then 
packed with a twist of iodoform gauze. This 
was permitted to remain forty-eight hours. 
The temperature became normal and re- 
mained so for fifty-four hours. After this the 
temperature ranged between 990 and ioi°, 
with rather frequent pulse for nearly three 
weeks, at the end of which time it again 
reached 106°. I saw her again at this time, 
when careful examination still failed to dis- 
close any signs of involvement of the perito- 
naeum. Hoping that the condition might be 
a temporary one, I suggested a plan of treat- 
ment with the idea that, if not successful, 
exploratory incision should be made. In less 
than forty-eight hours I was again summoned 
on account of recurring chills and high tem- 
perature. The abdomen was opened. There 
was nothing in the walls of the uterus that 
indicated inflammation. The tubes were 
healthy. Projecting from the orifice of the 
left tube was a small piece of lymph, with a 
similar portion on the surface of the left 
DISCUSSION. 
Dr. E. E. Montgomery : 
Dr. Noble has given us a very clear and 
able presentation of the subject of endo- 
metritis. The importance of this disease 
cannot be overestimated when we consider 
the probability of the extension of the disease 
from the uterine mucosa to that of the tubes 
and thence to the peritonaeum and ovaries, 
and the serious maiming of the individual, 
not only in the function of these organs, but 
in the general health during subsequent 
years. The almost absolute impossibility of 
restoring the function also indicates the im- 
portance of early treatment in such diseased 
conditions. ENDOMETRITIS—CONSIDERED CLINICALLY. 
9 
ovary. The ovaries and tubes were removed. 
The left was four times its natural size and 
contained a teaspoonful of greenish-yellow 
pus. The temperature at once subsided and 
the patient very promptly recovered. 
The rapid extension of the disease from 
the tubes to the pelvic structures indicates 
the importance of rendering the uterine canal 
sterile as early as possible. I do not believe 
that there is any better plan in acute sepsis 
following delivery than to thoroughly dilate 
the canal and curette the cavity, washing it 
out to render it sterile and drain by the intro- 
duction of a twist of iodoform gauze. This 
insures drainage, and there is a likelihood 
of relief of the trouble without further exten- 
sion. I believe that the majority of cases of 
endometritis, and consequently of salpingitis, 
are the result of regurgitation of fluid into 
the tube on account of obstruction to its 
passage through the cervical canal. In these 
cases we have desquamation of the epithelium 
with swelling of the mucous membrane. 
The narrowest portion of the canal is at the 
internal os, and thus we have here constric- 
tion due to inflammatory conditions, and the 
discharge which is increased in quantity 
makes its exit with difficulty. The uterus 
undergoes contraction in order to force out 
the fluid, and if the cervical opening is not 
readily distended, the fluid regurgitates into 
the tube. If such a patient is subjected to 
examination by a careless physician or one 
who uses the sound, infectious material may 
be carried into the uterus, and quickly extend 
to the tubes, with the development of serious 
trouble. These cases are greatly benefited 
by dilatation, moderate curetting, drainage 
and rest. I care not whether the drainage 
be accomplished by gauze or by the use of a 
stem with grooves upon its side, in order that 
the discharge may have a ready exit. I do 
not believe that dilatation is necessarily 
contraindicated, even when salpingitis exists, 
that is, where inflammation of the mucous 
membrane of the tubes is present. If we are 
able to secure drainage from the uterus and 
prevent further regurgitation and secure 
emptying of the tubes, I am sure that many 
cases will be relieved and the disease cured, 
where if this is neglected the patient will 
necessarily be subjected to an operative pro- 
cedure of a sacrificial character. 
In performing operations, every aseptic 
precaution should be observed. This is as 
important as in operations upon the peritoneal 
cavity. The vagina must not only be irri- 
gated but thoroughly scrubbed, and for this 
purpose there is nothing better than an appli- 
cation of green soap with a five to ten per cent, 
solution of creolin. The mucous membrane 
should be thoroughly scrubbed and washed 
before we proceed to disturb the uterus. The 
advantage of creolin over the bichloride is 
that it does not constrict the tissues. It 
leaves the parts in a more relaxed condition 
and less dry than after the application of the 
sublimate solution. Before proceeding to 
dilatation the cavity of the cervix should be 
curetted and disinfected. In the main I 
fully agree with Dr. Noble in regard to the 
importance of dilatation and curetting, and 
particularly of drainage and rest. Many of 
these cases can be treated* in this way and 
more accomplished in two or three weeks 
than by the ordinary methods in as many 
months. 
Dr. Joseph Price: 
You have all repeatedly heard my views 
upon this subject, and I scarcely feel like en- 
tering this discussion. I sometimes think 
that these methods of treatment are very 
much like locking the stable after the horse 
has been stolen. A woman returns from her 
wedding trip with advanced mischief, and I 
scarcely think that curetting, iodine and car- 
bolic acid, single or mixed, will save her from 
the mischief that follows. The discussion 
seems to fortify this statement. I will refer 
only to two cases. In a recent discussion in 
the New York Obstetrical Society a gentle- 
man spoke of a case of endometritis which 
he had curetted, drained and applied solutions 
to and sent her home well. In the course of 
two months she returns with two ovarian 
abscesses and pus tubes. These are removed 
and she gets well. Dr. Montgomery cites a 
case in which he etherizes, examines carefully 
and fails to find ovarian or tubal disease. 
He directed intrauterine treatment, and ova- 
rian abscess and disease of the tubes follow, 
for which he does an exploratory incision. 
In this case it would be interesting to know 
the causal relation that the primary trouble 
bears to the tubal and ovarian disease. 
Again, it would be interesting to know the 
causal relation of the dilatation, intrauterine 
treatment and traumatism to the abscess 
and the lymph he found in his exploratory 10 
CHARLES P. NOBLE. 
section. These are questions worth consid- 
ering in this discussion and in the manage- 
ment of similar cases. Our knowledge of 
this subject is accurate, and men should not 
grope in darkness and guess at what is best, 
nor should they resort to exploratory methods 
blindly. 
Dr. E. E. Montgomery: 
Dr. Price has evidently misunderstood my 
remarks. This woman had had a child a 
week before I saw her. The cavity of the 
uterus was distended with infectious material, 
which was scraped away. 
Dr. J. Price: 
I did not mean to criticise Dr. Mont- 
gomery’s case, except as a type of the vast 
number of similar cases on record. Gynae- 
cologists of the present day are coming back 
to the scientist’s position and accepting facts 
only. When we hear men talking about en- 
dometritis in all its varieties, it is natural to 
ask them if they can demonstrate such con- 
ditions with the uterus in their hands. I 
know very well that many years ago the con- 
dition of affairs that we find so commonly in 
the female pelvis did not exist to the same 
degree as at present. Pus tubes and ovarian 
abscesses were not by ninety per cent, as 
common as they are now. There is no ques- 
tion that the multiplication of railroads, the 
artificial methods of living, conventionalities 
of society and the vice that prevails in great 
cities predisposes to these troubles. We 
know that gonorrhoea is exceedingly common, 
and we know the causal relation that it bears 
to pelvic inflammatory trouble. Again, I 
know that where I find only one railroad in a 
town, I find but few cases of advanced mis- 
chief. Where we have no railroad in a small 
city there is almost a total absence of such 
troubles. I know this, not from one year’s 
experience, but from ten years’ study and 
most careful observation. I have just re- 
turned from a small city with a railroad only 
for a few years, and I took pains to ascertain 
the presence or absence of pelvic inflamma- 
tory trouble. I was told by four respectable 
physicians that such a thing did not exist. I 
went from this town to a railroad and manu- 
facturing centre, and examined some ten pa- 
tients and found advanced mischief—every- 
thing in the pelvis worthless so far as physio- 
logical function was concerned. I allude to 
these cases for two purposes. I am not quite 
willing to say that they are wholly due to 
vice and the advance of civilization, or that 
they are wholly due to gynaecology, but they 
are due to both. Six of the ten cases had 
been treated by six of the prominent gynae- 
cologists of America. Some had the cervix 
dilated and the uterus curetted. Another 
had had the cervix closed. All of these men 
have criticised my position on this subject. 
They have alluded to the fact that a paper 
has been read upon the subject by Dr. Price, 
saying that such methods have been criti- 
cised, and that certain troubles have been 
said to follow the treatment, and then have 
remarked that if the cases are properly 
selected and proper antiseptic precautions 
adopted, such mischief does not follow. 
These are their criticisms on my observa- 
tions, but the cases that I examined four 
days ago came from these very men. I have 
been on the alert, and have been making 
most careful notes and studies, and have had 
the assistance of not a few men of rare judg- 
ment and experience. 
Take these specimens shown by Dr. Cush- 
ing with malignant disease, extending to the 
internal os, no doubt with disease of the 
tubes and ovaries, and yet no evidence of 
endometritis. I have removed fifty-four uteri 
for malignant disease, and with many of 
these have been associated pus tubes and 
suppurating ovaries, but in not a single case 
have I found endometritis that I could not 
wipe away with a piece of cotton or gauze. 
I have removed eighty-two huge fibroids, 
another condition accountable for the endo- 
metritis so often found. In about every case 
I have incised the uterus with the specific 
purpose of studying this subject. It is ex- 
ceptional that I find that condition of affairs 
so much preached about and to cure 
which so much is done. Again, the men who 
talk the most about this subject, I venture to 
say, are the men who have incised the fewest 
uteri and have made the fewest microscopical 
observations. They talk loftily about scien- 
tific work and microscopical investigations, 
but some of them have never even extirpated 
a uterus,—had none to examine, none to 
take sections from. I do not mean to say 
that endometritis does not exist. I know 
better. I know that it begins as a catarrhal 
trouble at the vulva or vagina and extends to 
the cervix, to the endometrium, to the tube 
and ovary, and becomes a peritonitis, and ENDOMETRITIS—CONSIDERED CLINICALLY. 
11 
this saves the woman by sealing up every- 
thing. The mischief, however, has been 
done before the treatment is commenced, 
and in many cases the treatment is respon- 
sible when done for fancied disease. I enter 
this discussion purely to call a halt in all this 
tinkering. I do too many sections to save 
lives, and I find too much mischief to keep 
silent on a subject of this importance. 
Teachers are continually saying, with my 
paper in view, that the cases have been im- 
properly selected or improperly treated. The 
very class of cases that I am talking about 
are coming from these men. The Philadel- 
phia uterus does not differ from the New 
York or German uterus. The author of the 
paper this evening takes precisely the op- 
posite position from what is taken in New 
York. In the presence of tubal or ovarian 
disease, if he recognized mischief above the 
uterus, he would not dilate, or drain, or 
make local applications. I agree with him 
wholly in this. In New York the cavity of 
the uterus seems to be considered venomous. 
Huge pus tubes may exist, but the condition 
of the cavity of the uterus must be relieved 
before the tubes are removed. It matters 
not what is beyond the uterus—it must be 
prepared, or these germs will crawl up and 
kill the patient from sepsis. 
You will pardon me if I allude to an old ex- 
perience. I presume that I treated hundreds 
of women at the Midnight Mission. I never 
dilated once or curetted once, notwithstanding 
they were courtesans and chronic inebriates, 
some of them on the town for ten years. I 
never made any local applications, but put 
them on good food and iron. They were 
kept clean. Some may have had the vaginal 
douche. Some had not conceived for three 
to five years. Some of them—say, two per 
cent.—had sections for the removal of tubes 
and ovaries larger than the uterus. Of 
this group twenty per cent, conceived within 
six months after leaving the institution. This 
was the experience that put me on my guard 
and made me give the subject that considera- 
tion that induced me to take the position 
that I now hold. The last author on this 
subject—a Frenchman—has distinctly said 
that there is no evidence of endometritis in 
these cases, although the tubal disease is 
present. 
The author to-night has alluded to the 
simple and the chronic forms. It will re- 
quire a careful analysis of cases and study 
of specimens to make such a classification. 
Aveling has written of nidation and denida- 
tion. If you examine one hundred uteri, 
how many will show nidation, how many 
denidation, and how many endometritis ? 
You will find that they are different stages of 
•the same retrograde change. 
Puerperal peritonitis. I have watched a 
patient with puerperal peritonitis for three to 
five days, purging and using large intra- 
uterine douches. The peritonitis has con- 
tinued, and I have opened the abdomen and 
found a pint of muddy fluid and some adhe- 
sions and lymph of recent formation. I have 
found a black and angry tube, a tube so 
gangrenous that it could be peeled out of the 
crest of the broad ligament. 
This subject is too great to enter into fully 
and completely, but I have expressed myself 
plainly just as I feel and just as I act. I do 
feel that we have too much gynaecological 
tinkering, too many gynaecological operations 
and too many gynaecologists. The older 
gynaecologists are not doing so much mis- 
chief because they are men of much experi- 
ence and good judgment. They were all- 
around practitioners and general surgeons 
before practising gynaecology. It is the 
young men who graduate as gynaecologists 
who are doing the mischief, who have not 
had a varied experience in medicine, but want 
to do an abdominal section before even vacci- 
nating a baby. 
Dr. Noble: 
I wrote a note to Dr. Price, in view of this 
discussion, asking him to tell us how he would 
treat a case of fungous endometritis with re- 
sulting haemorrhages, and particularly a case 
of endometritis following abortion, where 
more or less of the ovum, or where a portion 
of the decidua, is retained. I should like him 
to tell us how he cures these cases without 
the use of a curette, or the finger used as a 
curette in the cases of incomplete abortion. 
Dr. J. Price : 
As a rule, the uterus empties itself. My 
experience in abortions is pretty much as 
that in midwifery. I am called to deliver a 
placenta, and when I arrive find it in the 
vagina. I have only exceptionally found the 
product of conception retained. Where such 
was the case I have removed it with my 
finger and washed out the uterus. As a rule, 12 
CHARLES P. NOBLE, 
I have been able to do this with my finger. 
I draw the patient well towards me, and 
without an anaesthetic use the finger, which I 
consider the best curette in these cases. 
Cases of abortion, with moderate irregular 
bleeding, I treated on general principles, 
building them up and, perhaps, giving a 
mixture of ergot if the trouble has gone be-* 
yond five or six months. 
Dr. Joseph Hoffmann : 
I see here and there over the room a scalp 
peeping out through the hair, and pretty 
soon this condition will be attributed to some 
form of coccus. This would be as logical as 
to ascribe all cases of endometritis to infec- 
tion. Suppose that these cases of endo- 
metritis are due to infection, how shall we 
get rid of the dirt in the vagina ? We know 
that certain experimentalists resort to oxalic 
acid and permanganate of potassium, but it 
has been discovered that even this does not kill 
all the germs. If they are infectious, what can 
soap do ? If oxalic acid and permanganate of 
potassium does not reach them, what will 
simple scrubbing do? If these germs are 
found all over, how is it that every woman 
does not have endometritis ? This is illogi- 
cal, for nothing is more certain than that 
many cases of endometritis are due to nothing 
else than mechanical conditions or physiolo- 
gical perversion. Dr. Noble criticises the 
gynaecologists who use electricity, thereby 
cauterizing the uterus, and then Dr. Noble 
uses chloride of zinc. If there is any cautery 
more powerful than chloride of zinc, I do not 
know it. It is a most irritant caustic, is 
dangerous, and you cannot control it. Dr. 
Skene remarks that to stop the secretion does 
not cure the disease, and wants to know how 
far the caustics may go to produce cicatriza- 
tion in the uterus, as they do outside. We 
all know that by caustics well applied we 
might entirely stop the secretion from the 
eye, but we should not have left a perfectly 
healthy membrane. How much more will 
strong caustics do this, if nitrate of silver and 
alum will ? As to carbolic acid, we know 
that this agent is capable of producing 
necrosis and slough by external application, 
so why its intrauterine application is regarded 
with so much complacency is puzzling. 
A word in regard to dilatation. It is said 
that we should dilate to permit a free flow of 
fluid. How many women are there who 
menstruate freely through an os no larger 
than the end of my pencil ? There is abun- 
dant haemorrhage, which escapes readily, 
which shows that operation is unnecessary. 
If the cocci are the cause of the trouble, will 
there not be increased danger from the 
lacerations caused by the dilatation ? 
Dr. Noble asks for proofs that dilatation 
causes subsequent trouble. I have watched 
a series of cases by certain operators, one of 
whom claims to be able to feel dilated veins 
in the broad ligament. If this is possible, he 
should be able to feel an enlarged tube and 
ovary. Now, when these same men have 
begun with the perinaeum and cervix, going 
on to dilatation and curetting, and have 
ended with abdominal section for pus tubes, 
is it not time either to stop claims for ultra- 
exact diagnosis or to confess that intra- 
uterine treatment may do serious damage 
when we least expect it so to do? Such are 
the facts. Though they may be ignored, 
passing them over does not reply to them or 
negative them. 
Dr. M. Price : 
I rise to ask if it is admissible to report 
cases and point out the men who sit in this 
Society who did the work? If it is, I have 
eight or ten cases belonging to this Society 
and I should be glad to report them, men and 
all. With some of the cases I have had to per- 
suade the patients that a criminal prosecution 
would end in failure and involve them in great 
expense, in order to save my brother Society 
men. I have a number of these cases that 
have been dilated and curetted by men in 
our Society. Dr. Noble asks for proof. I 
can give it to him if it is admissible. Piles 
of it, following the woman straight from the 
doctor’s office to her bed in a distant city, 
and her life at death’s door when I visited 
her, and a section necessary. The wonderful 
manipulative skill and diagnostic powers of 
this man could not detect the first symptom 
of disease, and he said to the woman in a 
most emphatic way, “ All you need is dilata- 
tion and intrauterine applications and you 
will have a baby inside of eighteen months.” 
That is one case only, but I have something 
short of a dozen of them. 
Dr. Charles P. Noble: 
I am glad that the subject has elicited such 
full discussion. I wish to call attention 
especially to peritonitis after labor without 
involvement of the tubes. Last year I ENDOMETRITIS—CONSIDERED CLINICALLY. 
13 
reported four cases in which there was 
peritonitis, and in three of which abdominal 
section was done, and in which there was 
found abscess in the broad ligament, the 
tubes being free and healthy. The fourth 
case was not conclusive. There was an 
abscess following abortion, which I opened 
in the loin. There was no fixation from the 
vagina. The only rational explanation was 
the breaking down of a lumbar gland. In 
three cases the abdomen was opened and the 
abscesses were evacuated by a second in- 
cision above Poupart’s ligament. I can also 
refer to the post-mortem work at the Phila- 
delphia Hospital, done by Dr. Parish, in 
which there was a large number of cases of 
peritonitis without involvement of the tubes. 
1 do not think that this is the rule even in 
puerperal cases. But this fact is the ex- 
planation of why in puerperal peritonitis the 
whole trouble often clears up and the patient 
gets entirely well without operation and sub- 
sequently bears children. 
I am sorry that the gentlemen who took 
issue with the line of treatment for endo- 
metritis laid down in the paper did not tell us 
what they do for the cure of their cases. So 
far as I can make out, they allow their 
patients to run on until they get pus tubes 
and then remove them. We are, therefore, 
to conclude that the result of their plan of 
treatment is to multiply the number of sec- 
tions. 
With regard to the relative frequency of 
diseased appendages in cities and rural com- 
munities, there can be no question that 
greater frequency of these conditions in 
cities is due to the prevalence of gonorrhoea 
and puerperal sepsis. I do not think that 
this is new. Bernutz, in 1840-50, found 
these diseases prevalent in Paris. He es- 
tablished the whole pathology of pelvic in- 
flammation before anyone thought of taking 
out the diseased tubes. If we had had care- 
ful investigations made ten centuries ago in 
large cities, I have no doubt the same diseases 
would have been found. 
Dr. Price states that he has never seen the 
evidences of endometritis. That is a strictly 
pathological question to be settled by the 
microscope. Pathologists tell us that they 
find this disease, and the question is whether 
you will take the testimony of the naked eye 
or that of the microscope. I know, from my 
experience with the curette, that there is a 
marked difference in the endometrium in 
different cases. Frequently you will find 
nothing that can be removed, while at other 
times the softened, thickened endometrium 
literally comes away by drachms. 
The contrast in these cases is so marked 
as to be convincing to anyone whose mind is 
constructed on ordinary principles. 
I have taken out pus tubes in cases that 
have had dilatation, curetting or the peri- 
nseum sewed up, but that does not prove that 
the condition of the tube had anything to do 
with the operation. There was no proof that 
the salpingitis was not present before opera- 
tion. 
In regard to the use of caustics, I stated 
that I used chloride of zinc only in cases 
where the appendages had been removed 
and the function of the organ was gone. I 
do not advocate its use in functionally active 
uteri, nor would I use it in such cases. With 
reference to cicatrization from tincture of 
iodine or carbolic acid, Dr. Hoffmann seems 
to have an unusual experience in the use of 
these drugs. I have never seen sloughing 
follow the use of either of these agents, nor 
do I expect to have cicatrization result. The 
supposed danger of the destruction of the 
glands of the cervix and uterus is purely 
imaginary. In the paper I clearly pointed 
out that there was a distinction to be drawn 
between a uterine leucorrhcea from conges- 
tion and an endometritis where there is a 
positive lesion in the uterus. PUBLICATIONS 
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