METRITIS AS A CAUSE OF MISCARRIAGE 
BY 
Charles Greene Cumston, B. M. S., M.D. 
BOSTON, HASS. 
Reprinted from the Boston Medical and Surgical Journal of 
August 29 and September 5, 12 and 19, 189g 
BOSTON 
DAMRELL & UPHAM, PUBLISHERS 
No. 283 Washington Street 
1895 S. J. PARKHILL & CO., PRINTERS 
BOSTON METRITIS AS A CAUSE OF MISCARRIAGE.1 
* 
BY CHARLES GREENE CUMSTON, B.M.S., M.D., 
Instructor in Clinical Gynecology, Faculty of Medicine, Tufts 
College; Member of the Socitti Franfaise d'ElectroMrapie, etc. 
Lecture I. 
Gentlemen : - You have seen at my clinics a num- 
ber of cases of metritis in all its various forms, and you 
have noticed how many of these patients have had 
miscarriages. It is for this reason that I would like 
to devote a few lectures to this important subject, 
particularly as it is just this class of cases the general 
practitioner is called upon to treat; and a knowledge 
of this subject will certainly be of value to you in your 
practice hereafter. 
It is necessary, in order to have a good idea of what 
is to follow, that I should put before you a few of the 
generalities of the pathology of abortion. 
Abortion is the expulsion of the product of concep- 
tion before the fetus is viable, in other words, before 
the end of the sixth month of gestation. 
The important writings of Garimond and Jacquemier 
demonstrated the real etiology, and the rapid progress 
of medical science has little by little excluded the so- 
called spontaneous abortions ; and I think it is safe to 
say that there is not such a thing as a spontaneous or 
idiopathic miscarriage. As the great Barnes says, an 
abortion indicates that there is a disease, or that the 
organism is overworked. A healthy woman, well 
built, and who has conceived from a healthy man, 
aborts with great difficulty. 
i Being four Clinical Lectures deliverpdatrtble 6BW1K Dispensary. 
Boston. 2 
Theoretically and practically, the causes of abortion 
are predisposing and determining. The immediate or 
effectual cause in all cases is the contraction of the 
uterus, which may be produced by external or internal 
irritation. 
To the first order belong traumatism, heat, cold, 
electricity, nervous emotions, etc. You should put 
little faith in what a woman or her friends say regard- 
ing a slight fall, a slip, jar of a carriage, a disagreeable 
smell or anger, as a cause of abortion. Medical 
literature is full of cases in which pregnant women 
have received bad shakings-up, falls from quite a 
distance, wounds, and even severe operations (such as 
laparotomy), without interrupting the progress of 
pregnancy. Cazeaux mentions the case of a woman 
who threw herself from a third-story window, fractured 
her arm, and had a normal labor at term. 
In the ordinary conditions of health, pregnancy is 
well protected against the most various accidental 
influences, and the cause of the habit of easy abortion 
must be looked for elsewhere. As Barnes says, a 
healthy uterus is not at the mercy of an emotional or 
diastalic accident; but it is in no way doubtful, I 
think, that very violent external irritations may pro- 
duce an abortion, especially in nervous subjects. 
Physical irritations almost always act by a partial 
separation of the placenta from the uterine wall, by 
the rupture of some vessels, or simply by producing a 
congestion of the uterus, which may subside or 
terminate in a short time by a utero-placental hemor- 
rhage. If the extravasation is of sufficient extent to 
suddenly destroy functionally a considerable portion 
of the placenta, the fetus dies at once, and very 
probably the commotion that is received by the uterus 
produces contractions which detach and expel the 
ovum. 
It sometimes happens, however, that even when 3 
there is a considerable extravasation, the embryo does 
not die ; the ovum is detached, and is then expelled 
with a living embryo. 
There are cases, gentlemen, in which a jar will 
directly produce an excito-motor action of the uterus, 
or in others death to the fetus. External violence 
may act directly over the region occupied by the 
uterus, and wound the fetus. Severe or sudden mental 
shocks act by means of the nervous system of the 
woman by directly producing uterine contractions, with 
death to the embryo, or by causing a congestion of the 
uterus and utero-placenta] hemorrhage. 
Although uterine contractions may be set up by 
external irritation some distance from the genital 
organs, the most important and dangerous are certainly 
the internal irritations which act on the internal aspect 
of the uterus. You all are aware that foreign bodies 
introduced into the uterine cavity will cause abortion. 
As in the above-mentioned irritations, the uterus con- 
tracts by a reflex action; but the starting-point of this 
reflex is the uterus itself, and not in other parts of the 
organism. 
To this category of internal irritation belongs the 
exit of blood from the vessels, and even the ovum, in 
certain cases. The hemorrhages which occur at the 
surface of the ovum come from the chorion or the 
placenta', and may provoke a premature labor, not only 
resulting in the death of the fetus, but also by irritat- 
ing the internal aspect of the uterus, starting up 
contractions. 
According to Garimond, if the collection of blood is 
situated between the chorion and the uterus, the 
muscular fibres show their irritation by contracting, 
the hemorrhage acting like a foreign body; but it is 
tolerated when it accumulates in the interior of the 
ovum. If the ovum is detached, with or without a 
collection of blood, it acts in the same manner, because 4 
the friction that it produces on the interior of the 
uterus excites the nerves of the organ, thus producing 
the labor pains. 
Now, as to the cause of the death of the fetus, the 
question is not fully settled. The majority of the 
French and German authorities admit that the fetus, 
when once dead, acts like a foreign body, and after a 
variable time starts up uterine contractions which 
expel the ovum. But there are some of the present 
German obstetricians who are opposed to this theory, 
and give the following explanation in its stead. The 
dead fetus does not play the part of a foreign body; 
its action on the contractions is of an entirely different 
nature. With the arrest of development of the ovum, 
the stimulant of the growth and proliferation of the 
muscular fibres of the uterus ceases. Now, if the 
death of the embryo takes place slowly, the same 
process will occur in the uterine tissue; there is con- 
sequently arrest of the reflex growth of the muscular 
tissue of the uterus, or, as may be admitted, the usual 
relaxation of the organ is no longer in a favorable con- 
dition, while the muscular fibre having stopped grow- 
ing must in time contract. Thus, according to this 
theory, it is not the foreign body but the disappearance 
of the cause that brings about labor, namely, distention 
of the uterus and absence of contractions. 
Although this theory is ingenious and is in accord 
to a certain degree with the hypotheses regarding 
muscular contraction, Rouget's theory is certainly of 
doubtful value, and is as follows: anything which 
prevents the work of nutrition of a muscle causes the 
tendency of lengthening of the fibres to disappear, 
while the elasticity remains alone in play, and con- 
traction is the result. As is pointed out by Zielinski, 
it would appear to me that in this theory there is a 
confusion of contractility and retractibility which are 
two very different properties of the uterine muscle. 5 
The most plausible explanation of the action of the 
dead fetus is probably that given by Barnes : After 
the death of the fetus (if this is the first act) death of 
fetal and maternal placenta and the envelopes comes 
on progressively, the vascular connections between the 
uterus' and placenta are cut off, and the uterus being 
no longer stimulated to growth, takes on the condition 
of a non-pregnant organ. There is involution, the 
circulation of blood becomes less active, the muscular 
tissue undergoes fatty metamorphosis, and the whole 
organ decreases in size. At the same time the chorion 
undergoes an involution of the same nature. The end 
of this mucous involution is exfoliation or detachment. 
Once this separation is accomplished the ovum is free 
in the uterine cavity, and is now only a foreign body. 
When the uterine retraction, which accompanies invol- 
ution, has reached a certain point, the dead ovum 
comes in contact with the retracted uterine walls, and 
the retraction, which up to this time was only passive 
and atrophic, is replaced by active muscular contrac- 
tions, produced by reflex action. 
To internal irritations capable of producing mis- 
carriage, I might add distention of the uterus. This 
may be caused by an abnormally large ovum, as in 
twins, hydramnios or other similar conditions, which 
act on the entire internal surface of the uterus by 
producing over-distention of the muscular fibres of the 
organ. On the other hand, the ovum may be normal, 
but the walls of the uterus are limited in development 
by loss or decrease in their elasticity. 
In both conditions, the extreme distention of the 
uterus is sometimes sufficient to cause premature con- 
tractions and thus interrupt the progress of pregnancy. 
It is probable that in metritis the coexistence of lesions 
of the endometrium and muscular tissue is constant. 
According to de Sin^ty, Courty and Schroeder, inflam- 
mation of the endometrium rapidly invades the paren- 6 
chyma of the organ, resulting in metritis and para- 
metritis. 
No matter what may be the etiological factor, the 
nature or primary seat, the inflammatory process 
invades the neighboring tissues by way of the lymph- 
atics, veins, connective-tissue elements - from the 
endometrium to the parenchyma of the uterus and 
periuterine tissues. But in most of the cases, you 
will find the lesions will predominate in some one part 
of the organ, as the endometrium or uterine paren- 
chyma: consequently pathologists have classified in- 
flammations of the uterus into two groups, endo- 
metritis and parenchymatous metritis. 
The same division is to be made in the pregnant 
woman, because the endometrium here plays the all- 
important part; and as I have already mentioned in 
another lecture2 the adhesions between the decidual 
and the muscular tissue of the uterus becomes less and 
less intimate as gestation progresses. Parenchymatous 
metritis is not so important a factor in the etiology of 
abortion as is endometritis, its influence being of an 
entirely different kind. 
I shall only speak of the chronic metrites, which are 
far better understood than the acute types. Inflam- 
mation of the endometrium may invade any of the 
three deciduae, the decidua vera, reflexa and serotina. 
In each case, the histological process is the same; it 
is either an interstitial endometritis, consisting of an 
infiltration of small embryonic cells, often arranged in 
rows, according to Veis, as well as a proliferation or 
alteration of the decidual cells ; or else it is a glandular 
endometritis, which is a hypertrophy and hyperplasia 
of the uterine glands; and lastly, it may be a mixed 
endometritis, with or without vascular lesions. 
According to the nature of the lesions, the changes 
2 Hemorrhagic Metritis. International Clinics, Fourth Series. 7 
in the decidua vera present different anatomical char- 
acters. 
In hyperplastic endometritis the decidua is thickened 
to even double the normal, and continues to increase 
as it comes nearer to the fundus. This hypertrophy 
is often, uniform and regular, giving the surface of the 
mucosa an even and smooth appearance. Interstitial 
inflammation predominates in this type and may go as 
far as real sclerosis and even to formation of abnormal 
adhesions. Hemorrhages occur quite often. Kasche- 
warowa found muscular fibres in parts of the mucosa 
nearest to the uterine walls. 
In the tuberous endometritis, also called polypoid, 
instead of an even hyperplasia as in the preceding 
type, the decidua presents numerous projections, which 
may .attain to a centimetre and a half in height- They 
are rather irregular, generally pedunculated, and look 
like polypi. Those which are sessile take on various 
shapes like folds, nodosities, bands, etc. These ine- 
qualities are usually very vascular and are made up, 
according to Dohm, Spiegleberg and Mars, of large 
decidual cells. Tarnier and Budin, when writing in 
1888, said that in all the cases reported up to that 
date, pregnancy had not gone beyond the fourth 
month. The development of the ovum was very much 
interferred with or else hemorrhage occurred and pro- 
duced abortion. 
Cystic endometritis, as its name indicates, has for 
pathological changes the development of numerous 
cysts in the midst of the decidua. These cysts vary 
in size from that of a pea to a walnut and contain a 
colloid substance. The surrounding parts of the 
decidua are in a state of hypertrophy and small hemor- 
rhagic foci are to be found. This cystic degeneration 
is in some cases so pronounced that it might be mis- 
taken for an hydatidiform mole. Leopold, Winckel 
and Veit believe that the cysts are produced by the 8 
distention of the uterine glands, which are filled by 
their retained secretions. Maslowsky examined two 
deciduie from a woman who had three abortions in one 
year, all occurring at the end of the second month, and 
found that in both specimens the decidua was riddled 
with small cysts which were partially lined on their 
interior by a glandular epithelium. 
The production of catarrhal endometritis is due to 
the inflammation, hypertrophy and over-activity of the 
uterine glands. When the decidua is irritated and in 
a condition of hyperemia, these glands, which are now 
generally regarded as filters and not organs of secretion, 
filter the excess of liquid which they receive from the 
neighboring capillaries. There then form between the 
decidua vera and reflexa what may be termed hydror- 
rheic pockets, with the result that these deciduae, .which 
are united at the end of the third month of gestation, 
remain separated. I believe that it is quite safe to 
say that an endometritis can be the cause of a de- 
cidual hydrorrhea; but all writers do not consider it 
as the only factor in the production of a watery dis- 
charge. 
Hemorrhagic endometritis was the subject of a 
clinic given here some time since, and I shall be brief. 
Winckel has termed this affection as apoplexy of the 
decidua, which is in a condition of hypertrophy with 
dilated vessels, while extravasation of blood is to be 
found both at the internal and external aspect. Budin 
has reported a very demonstrative case in which 
there was a hemorrhage of the decidua some distance 
from the placenta, while on the decidua, which was 
hypertrophied, were some vessels, which near the 
clot were dilated and moniliform, such as are met with 
in neo-membranes. 
Purulent endometritis is a very rare form, only a 
few cases having been reported. It is simply a puru- 
lent infiltration of the decidua and also in some cases 9 
the chorion. The starting-point is probably an inflam- 
mation of the decidua vera. 
Now, gentlemen, it is very infrequent to meet with 
a case in which one of the above-mentioned forms is 
perfectly typical; generally they are combined, for 
example., a hyperplastic will be found accompanying a 
polypoid endometritis and then we have the mixed 
variety. 
Inflammation is much less likely to invade the 
decidua reflexa, because atrophy takes place much 
earlier in this than in the decidua vera, the regressive 
metamorphosis beginning after the first month of 
gestation; and Veit states that he has never seen a 
characteristic interstitial inflammation of the decidua 
reflexa. It is only in catarrhal endometritis that it 
really plays an important part. However, there are 
some recorded cases in which the decidua reflexa was 
found thickened, and although very rarely, hemor- 
rhages in its substahce were noted, while Dohm has 
even reported a case of polypoid endometritis. 
Now, if you carefully examine the expelled pro- 
ducts of a miscarriage and on the external aspect of 
the chorion you find a quantity of rather friable yel- 
lowish tissue, you must be very careful not to at once 
make a diagnosis of endometritis, because this mass of 
tissue, which undoubtedly may be the decidua in a 
state of hypertrophy, may also be simply fibrous clots of 
a yellow or whitish color and easily recognized by their 
stratified aspect. Consequently, you should make a mi- 
croscopical examination, which will remove all doubts. 
The important changes of the decidua naturally af- 
fect the other membranes of the ovum. The chorion 
may be very thin and friable, while its villosities may 
develop irregularly and undergo a fibro-fatty, or even 
myxomatous, degeneration. The amnios may be only 
slightly united to the chorion or may even be separ- 
ated f. om it by a sanguineous collection. The amni- 10 
otic liquid becomes opaque, brown and sometimes even 
bloody. Consequently, you will keep in your minds 
these secondary lesions of the membranes which 
show their changes by partial detachment or adhe- 
sions. If the inflammatory lesions are only seated in 
the decidua serotina, you have to do with placental 
endometritis, which presents the same types as de- 
cidual endometritis, so I will not repeat them here. 
As to their histology, I shall use the classification 
of Zinowieff, who has made some remarkable studies 
on the pathology of the placenta in abortion. 
First, we have pathological changes in the placental 
vessels with troubles in the circulation, among which 
may be mentioned, as the most important, intra- 
placental hemorrhages, circumscribed or diffused, and 
a periarteritis of the placental vessels which produces 
a diminution in their calibre and a fatty degeneration 
of the villosities. 
Secondly, a proliferation of connective tissue, 
which forms the so-called diffused or circumscribed 
interstitial placentitis. 
Thirdly, changes in the decidual cells and villosi- 
ties, which consist in a colloid, fatty, granular, hya- 
lin, or fibro-fatty degeneration, with atrophy and 
change in shape and size of the villosities. 
To this last, belongs the four cases of abortion re- 
ported by Colucci. They all took place between the 
tenth and fifteenth week. The villosities of the fetal 
placenta presented a hypertrophy of their epithelial 
membrane and an atrophy of their connective tissues. 
These changes coincided, according to this writer, 
with an endometritis. Veit, Winckel and others ad- 
mit that a placental endometritis is often the cause of 
white infarction, and always that of a placenta margi- 
nata, the latter always being, according to Veit, a 
characteristic sign of endometritis. 
A decidua serotina endometritis may result in a by- 11 
pertrophy or adhesions of the placenta, these being 
usually partial, seldom total. Hypertrophy of the 
placenta is easily recognized by a careful inspection 
of the specimen. Its increased size and weight, in 
relation to the size of the fetus and the duration of 
pregnancy', are also quickly estimated. As to partial 
or total adhesions which are commonly met with in 
practice, they play an important part, of which I shall 
speak later. 
Chronic parenchymatous metritis is generally of 
old standing ; the uterine muscle has lost its elasticity ; 
while the predominating histological change is a pro- 
liferation of the connective tissue with resulting scler- 
osis. The muscular fibres, which in the beginning 
were in a state of hypertrophy, softened and red, 
atrophy, become hard to the feel, and take on a whit- 
ish color. These changes are due to an embryonic 
proliferation occurring around the vessels. When the 
uterine parenchyma has been acted upon by an in- 
flammatory process of long duration, it is infrequent 
if there is not at the same time some remains of a 
perimetritis with adhesions producing deviations of 
the organ and traces of salpingitis. The uterine 
mucosa is always more or less diseased. 
The question now comes as to how metritis pro- 
duces abortion and I will try to demonstrate this 
problem to the best of my power. The uterine 
mucosa is a soil more or less fertile, in which the 
ovum may grow and develop, or perish. If it is 
badly diseased, it is unsuited to hold the impregnated 
ovum; but if the endometritis is not very severe or 
generalized, the ovum grafts itself on to it, develops 
and may go to a full term ; however, it is more fre- 
quent to meet with an interrupted gestation sooner or 
later in these cases. The consequences are the same 
for both mother and fetus when an inflammation of the 
decidua takes place during gestation, and its influence 12 
on the evolution of the ovum is always of the worst. 
Endometritis, and metritis in general, bring about 
sterility or various complications during gestation, 
labor or the post partum. The difference depends on 
the severity, the nature, the condition of the patient and 
other factors which are sometimes difficult to make 
out. The miscarriage in these cases is only one of the 
symptoms of endometritis, but by far the most impor- 
tant and frequent. 
It may occur in several ways which I will now con- 
sider : 
By the death of the fetus. Following the changes 
in the decidua produced by the endometritis, the vil- 
losities of the chorion become diseased, while the un- 
derlying structures become so in their turn until the 
ovum is also in a pathological condition. On account 
of repeated congestion, friability and rupture of the 
vessels, the decidua may also become the seat of extra- 
vasation of blood which compresses and alters the villosi- 
ties of the chorion, resulting in the abolition of their 
functions and reducing the decidua serotina to a condi- 
tion of uselessness, with death to the fetus and later its 
expulsion from the uterine cavity. 
The second manner of miscarriage is by detachment 
of the ovum. If a hemorrhage suddenly occurs in 
the decidua vera or serotina, or if it is considerable in 
amount, it produces a detachment of the ovum which 
is followed immediately or in a few days by a miscar- 
riage. Hydrorrhea produced by a catarrhal endome- 
tritis acts in the same manner. When the liquid is 
suddenly expelled in considerable quantity, the sud- 
den decrease in size of the uterus may produce a 
detachment of the ovum and contractions of the 
organ. 
Hyperplasia of the decidua, especially the serotina, 
often exercises its bad influence on the fetus by cut- 
ting off its nutrition. The connective tissue or a 13 
proliferation of embryonic cells around the villosities 
and the cotyledons which are thus more or less en- 
croached upon, produce a diminution in the calibre of 
the vessels and a fatty degeneration of the villosities, 
while the fact that healthy parts of the placenta be- 
come more and more reduced in extent, soon act on 
the fetus, which finally dies. Now, a sclerous hyper- 
plasia of the decidua or an induration of the placenta 
may also produce a miscarriage by loss of elasticity of 
its tissues, which can only follow the growing uterus 
with difficulty, and there finally comes a time when a 
partial detachment takes place. 
The third manner of miscarrying is by rupture of 
the membranes. As I have already said, the pathol- 
ogical condition of the decidua may act on all the 
membranes ; and when they are badly nourished, they 
become friable and break by the least movement. 
This is enough to show you how premature rupture 
occurs, with a resulting miscarriage or premature labor. 
Sometimes an inflamed decidua, by modifying its 
nutrition, increases the irritability of the uterus to 
such an extent that the normal development of the 
ovum is enough to bring on painful contractions which 
usually expel the ovum. In this case, the miscarriage 
is not preceded by either detachment of the membranes 
or death of the fetus. As to endometritis of the cervix, 
when there is much secretion, the spermatozoa cannot 
enter the cavity of the uterus on account of the 
mechanical obstruction produced by the plugs of 
mucus in the canal. But cervicitis can also cause mis- 
carriage, and Whitehead believes that 73 per cent, of 
miscarriages are provoked by diseases of the lower seg- 
ment of the uterus. Barnes believes that although the 
cervix has no direct relation with the ovum, its con- 
nection with the corpus uteri is sufficiently intimate 
for a severe cervical hyperemia to produce considerable 
afflux of blood and nervous disorders in the body of 14 
the organ. An extravasation of blood, with miscar- 
riage may result. 
As I have already remarked, in chronic parenchy- 
matous metritis, after perivascular embryonic prolifera- 
tion and ultimate sclerosis, the uterine walls lose their 
natural elasticity and can no longer dilate as the ovum 
increases in size. In consequence of this rigidity, the 
organ can only tolerate the ovum up to a certain time ; 
and when the germ has developed to a size which 
distends the uterine walls to their limit, contractions 
begin and determine the miscarriage. As paren- 
chymatous metritis is of long duration, miscarriages 
may occur often and usually at about the same time of 
gestation on each occasion, because the walls can only 
be distended just so far. Leopold thinks that this 
metritis is quite sufficient explanation for repeated mis- 
carriage in many cases; and a case is mentioned by 
Bick of a woman having a chronic metritis, and who 
aborted twenty-four times, always at the third mouth 
of pregnancy. 
I have seen many cases of endometritis and metritis, 
in whom sterility was present, or who could never 
carry their pregnancies further than the first three or 
four months. In many of them labor at term was 
brought about by proper surgical treatment of the 
diseased uterus. 
I have now finished with the pathology of miscar- 
riage, and in the next lecture I shall take up the 
various forms of metritis and their relations to 
abortion. 
Lecture II. 
Gentlemen : - In this lecture, I propose to study 
the different varieties of metritis that produce miscar- 
riage. The subject is a long but interesting one. and 
I trust that you may find it so. 15 
According to the modern theories, it may be said 
that all inflammations of the uterus are of infectious 
origin. It is now a long time since Schroeder put 
forth this idea; but it was not generally accepted 
until the writings of Steinschneider and Winter on 
gonorrhea*, and those of Goenner. Doederlein, Straus, 
Sanchez Toledo, Peraire and Widal on puerperal 
fever had appeared. The most frequent infection is 
either exogenous or hetero-infection by germs coming 
from without. It is also an established fact that in 
some cases, more infrequent however, the infection 
comes from the uterus or vagina, in which case you 
have a real auto-infection. In the healthy female, 
the vagina affords a home to a host of virulent bac- 
teria which enter into action whenever favorable cir- 
cumstances are present, as, for example, any debris 
that may remain in utero after a labor or miscarriage. 
According to the part attributed in the etiology of 
the abortion, the metrites may be divided into two 
groups. The first have an undoubted and marked in- 
fluence in predisposing patients to abort; these are 
puerperal and gonorrheal infection. Those of the 
second group are not so characteristic in the produc- 
tion of miscarriage, either on account of their nature 
or the degree of their influence on interrupting preg- 
nancy. In this class I include syphilis, tuberculosis 
and the general infectious diseases. 
We will now proceed to the study of each one sep- 
arately, and will begin with puerperal metritis. It is 
now generally admitted that a great number of metri- 
tes have their origin in a septic inflammation brought 
on by a labor or miscarriage, and have for their agent 
the streptococci coming from the vagina, and usually 
brought from without by means of unclean instru- 
ments or hands. 
After labor, the uterus even when normal, or after 
an abortion, presents a most favorable soil for culture 16 
to all infectious bacteria. At the same time the organ 
is in a particular condition of hyperplasia and conges- 
tion, which demands certain special hygienic conditions 
in order to progressively disappear. Now, these con- 
ditions are unfortunately very often neglected, and it 
is for this reason that post-puerperal metritis is so fre- 
quently met with. It occurs especially when the 
labor or miscarriage, as the case may be, has been 
abnormal, and may continue forever in a chronic 
form if an antiseptic treatmeat of the most rigorous 
kind is not immediately put into action. As after 
labor, there is only a thin layer of mucosa made up 
of a stratum of young cells, and the bottoms of the 
glandular culs-de sac are widely open, it is evident 
that an infection which is deep in its origin, will re- 
main deep. 
In post-partum endometritis, if the uterine muscles 
contract promptly, thus reducing the surface of the 
cavity of the organ, the mucosa is massed together, 
giving it the appearance of thickness, and little by 
little during reparation, it will enclose in its depth the 
tissues primitively invaded by septic inflammation, 
and a chronic condition is set up from the beginning, 
This metritis often produces sterility; but you must 
not think for a moment that conception or pregnancy 
is not possible in these cases. However, it is excep- 
tional that labor takes place normally or at term, and 
from my observation, miscarriage is extremely fre- 
quent, and I do not hesitate to say that metritis is the 
cause of the greatest number of abortions. 
I must not forget to mention, as an important factor 
in the production of endometritis post-partum, the too 
hasty getting up of the patient after labor. It is a 
hard matter to decide what pathological type a post- 
partum endometritis due to infection will assume. I 
have met with many varieties, most generally diffused, 
with tendency towards the plastic, catarrhal or hemor- 17 
rhagic types, although I am inclined to believe that 
the latter only occurs when there remains some debris 
of the decidua in the uterine cavity after an abortion, 
and that in this case there is no infectious process. 
Beside puerperal metritis, there are other metrites 
which occur after attenuated septic conditions, and pro- 
bably have their starting-point in the vagina, in which 
altered secretions or the blood of menstruation form 
the culture media for the development of the patho- 
genic agent; and a traumatism or severe congestion 
which causes a disturbance or lesion of the lining epi- 
thelium will start up an inflammatory process that 
rapidly extends over the entire mucosa. This form 
of metritis will also facilitate miscarriage. 
We now come to the important subject of gonor- 
rheal metritis; and although it is only recently that 
this type of uterine inflammation has been admitted 
by pathologists, still Barnes and Schroeder taught 
that gonococci infection played an important part 
in the etiology of miscarriage. Richard and Bousquet 
consider it as very frequent. The uterus is a more 
favorable medium for the growth of Neisser's organ- 
ism than the vagina, on account of the special epithe- 
lial lining of the latter, as has been demonstrated by 
Steinschneider and Eraud. 
Gonorrheal metritis is often primary, while the 
specific vaginitis is the consequence, the latter condi- 
tion being rather a desquamation or maceration than 
an inflammation proper. This, I repeat, is often the 
case, but not always so, for I have seen cases in 
which the vaginitis was certainly primary, and under 
proper treatment the uterus was not infected. 
The cervix is the primary seat of infection of the 
uterus, and from this the gonococcus invades the re- 
mainder of the organ. The infection may remain for 
a long time localized in the cervix in an attenuated 
and latent state, and then after t-raumatism, fatigue or 18 
labor, the infection lights up and quickly invades the 
entire organ, even extending to the tubes and peri- 
toneum. 
Noegerrath even went so far as to say that 75 per 
cent, of women infected with gonorrhea had endome- 
tritis and perimetritis following labor. Pozzi does 
not think this proportion too large if perimetritis be 
replaced by salpingitis. Sterility is a common conse- 
quence of this form of metritis and especially so if 
the adnexa are involved. However, gonorrheal en- 
dometritis is met with in pregnant women. It often 
begins before pregnancy, and the presence of the fe- 
cundated ovum in the cavity of the uterus, only aggra- 
vates the pre-existing inflammatory lesions; and Veit 
is even of thr opinion that this always happens, the 
endometritis only showing itself for the first time dur- 
ing pregnancy, although it was there before this took 
place. But let me add that a healthy uterus can be 
infected during gestation, and this certainly does 
sometimes occur. 
The pathological type that this form of metritis 
takes in pregnant women is, in the majority of cases, 
pyogenic; and there are also, perhaps, certain hyper- 
plastic forms. Whatever this may be, it often inter- 
rupts the pregnancy, and Muller considers it a fre- 
quent cause of habitual abortion. Winckel believes 
that with the progress of the disease a similar patho- 
logical process takes place on the surface of the ovum, 
which results in rupture of the membranes. 
Of all infectious diseases which complicate preg- 
nancy, syphilis is the most important, especially on 
account of its great frequency. Its influence on ges- 
tation has been known for a long time, and it is 
exceptional that gestation goes on to term without 
some mishap. According to Blaise, the proportion of 
miscarriage and premature labor is 36.8 per cent. ; 
while Legrand has found about the same, namely, 19 
35.2 per cent.; in other words, about one miscarriage 
out of every three full-term pregnancies. Syphilis 
varies greatly in its effects, according to its age and 
whether the subject has followed a regular course of 
treatment or not. If the woman was syphilitic before 
conception', Fournier believes that she is more pre- 
disposed to miscarriage than if she contracted the 
disease during pregnancy. It is a fact that a large 
proportion of abortions follow a syphilis contracted 
before conception. In this case several miscarriages 
will succeed one another ; but as the disease becomes 
attenuated, the fetus will develop to a greater age, and 
dies more and more late in gestation, and may even 
go to term, being born with or without syphilitic 
symptoms, and only die later. 
It is also a fact that the severity of the syphilitic 
accidents and the abortions vary in an inverse rela- 
tion to the age of the syphilis ; but it is impossible to 
calculate how much time it will take for an untreated 
maternal syphilis to lose its effects on the ovum. If 
the subject becomes infected at the same time as con- 
ception the danger is about as great, and, as a rule, 
she will abort; but when the disease is contracted dur- 
ing gestation, and especially during the last three 
months, there is much less chance of the pregnancy 
being interrupted. 
Syphilis- in the father may not only infect the 
mother and through her the fetus, but may, although 
exceptionally, infect the child directly, as Fournier 
has observed ; and in this case, if the mother con- 
tracts the affection, it will be from the fetus through 
the placental circulation. The majority of writers 
attribute the production of abortion in syphilis to the 
fetus. The syphilitic virus, whose nature is still un- 
known, passes from the mother to the fetus and infects 
it, while the serious organic lesions produced by the 
infection, death, maceration, finally produce its ex- 20 
pulsion from the uterus. There are many cases of 
this kind, but I am of the opinion that they are not as 
common as those in which syphilis has produced 
lesions of the uterus. We have many cases on record 
of syphilitic metritis when there was no pregnancy, 
and I believe that when we shall have at our disposal 
the same means of diagnosis for syphilitic-metritis 
that we possess for the tubercular variety, recognition 
of the affection will become of ordinary occurrence. 
Bonnet records many cases of syphilitic metritis in 
his thesis, and even mentions some in which the sub- 
jects who had always had a normal uterus, were sud- 
denly seized with an acute metritis at the time that 
the syphilis appeared. He concludes that these uter- 
ine symptoms met with in the very early stage of 
syphilis are the result of a characteristic anatomical 
lesion of the uterus, which develops by the presence 
of the general infection. 
Secondary syphilis acts on the uterus in the same 
manner as on the liver, kidney and other viscera; and 
as the uterus is the principal organ of woman, and for 
that very reason is, like all active organs, subject to 
disease, it is one of the first to undergo the bad influ- 
ence of this general infection. It becomes diseased 
and the symptoms of this anatomical change are 
leucorrhea, metrorrhagia and pain, symptoms which 
are not to be directly attributed to the syphilis, but to 
a well-developed metritis, which has been produced by 
the syphilitic infection. The case of a young syphil- 
itic woman is recorded by Petit, who developed a typi- 
cal'endometritis during the secondary stage, while the 
genital organs presented no signs of specific acci- 
dents. 
I have recently had a young married lady under my 
care, who consulted me for great pain and swelling in 
her nose. Another surgeon had told her she had poly- 
pus and advised removal. Not finding any polypus, 21 
and after careful examination, I made the diagnosis of 
syphilitic necrosis of the bones of the nose and placed 
the patient on protiodide of mercury and iodol. She 
did so well that in ten days' time the lesions of the 
nasal bone^ had about disappeared. I then sent her 
to Schintznach in Switzerland for the summer. She 
returned in the fall perfectly free from any manifesta- 
tion of the disease, when early last winter she devel- 
oped as acute a type of metritis as you could wish to 
see. Under mercury and iodol internally and a little 
local treatment this metritis subsided, and according to 
my advice, the young lady is at present taking a cure 
at Luchon. Now, this patient who had been divorced 
some two years before she came to me, had never had 
any skin or other accidents until those of which I 
have spoken, and knowing the social position and 
reputation of my patient, I feel certain that the 
metritis in her case could have no other explanation 
than that of the tertiary form of a syphilis which she 
had contracted from her husband soon after their mar- 
riage. 
Heitzmann believes that the proliferation of the in- 
ternal lining of the vessels is a characteristic sign of 
syphilitic metritis. 
Admitting that the non-pregnant uterus may be the 
seat of a syphilitic metritis, it will be all the more sus- 
ceptible to this affection during pregnancy, which ren- 
ders it a locus minoris resistentice in the true sense of 
the term. It is true that in order to prove this, we 
have no histological or bacteriological data, but there 
are clinical facts on which we can base this hypothe- 
sis. When the feticide action of syphilis is severe, 
when both parents are infected to a high degree, the 
fetus is generally killed by the syphilitic virus, and is 
expelled sometime afterwards in a macerated condi- 
tion. In this case the endometritis is no longer a 
cause ; it may even occur after the death of the fetus, 22 
according to Duncan and others. But if, for example, 
the mother is alone infected, especially if syphilis was 
contracted after conception, and if pregnancy is 
troubled by pains, leucorrhea and slight hemorrhages, 
the fetus will come away living, and there will be a 
retention of the hypertrophied decidua with well 
marked changes in the decidua serotina. Here, 
gentlemen, I do not see how this condition of affairs 
can be explained in any other way than by a syphilitic 
endometritis. 
Infection of the fetus and endometritis may also 
coexist, in which case pregnancy is interrupted,-the 
fetus being expelled in a macerated state, and the 
hypertrophied placenta is retained. This hyper- 
trophy of the placenta, which is so often related to 
endometritis of pregnancy, has been put forward by 
Pinard as symptomatic of syphilis; and I have seen 
this pathological condition in several syphilitic sub- 
jects whose children were born with evident syphilitic 
lesions, but this question will have to be studied, since 
as yet nothing is established regarding the histology 
of syphilitic placenta. The existence of primary 
genital tuberculosis is no longer doubted. In 1884 
Fernet demonstrated it in women, showing its sexual 
origin following coitus with a tuberculous male. 
The tubes are most always the starting-point of 
tubercular lesions ; but tuberculosis of the uterus is 
also known and it is a positive fact that it can be 
primary, following direct inoculation. 
Pozzi considers it an infrequent disease, while 
Jouin and others believe that tubercular endometritis 
is more common than tuberculosis of any of the 
other genito-urinary mucosa, for the reason that the 
endometrium is soft, spongy and very rich in tubu- 
lar glands, all of which conditions are especially 
favorable for the development of an essentially ane- 
robic bacteria. The disease is, in the first stage, a 23 
tubercular degeneration of the uterine mucosa, but 
the parenchyma of the organ may also be invaded. 
There are two types of tubercular endometritis, one 
is of tubal origin or descending endometritis, the 
other is ascending and probably sexual in origin ; the 
first type is by far the most frequent. The diagnosis 
has often been verified by microscopical examination 
and by the inoculation of guinea-pigs or rabbits. 
Sterility is very common as long as the tubercular 
inflammation exists in the mucosa, although Cooper 
mentions a case in which conception took place in a 
tuberculous uterus, the woman dying in the third 
month of gestation from a spontaneous rupture of the 
organ. 
When endometritis or salpingo-endometritis occurs 
during pregnancy, abortion is nearly always unavoid- 
able. The following case, due to Gusserow, is in- 
structive. A woman was afflicted, after conception 
had taken place, with a descending salpingitis and a 
tubercular endometritis, and aborted at the fifth 
month. The post-partum was complicated by a 
puerperal infection and acute miliary tuberculosis, 
whose progress was found to be due to a thrombus 
derived from a large vessel in the uterine walls, in 
the centre of which was found Koch's bacillus. 
Secondary tuberculosis is much more frequent, that 
is to say, a tuberculosis developing during a tubercu- 
lar degeneration in some other organ, especially the 
lungs. You consequently can have a secondary tuber- 
cular endometritis in pulmonary tuberculosis, as well 
as a pulmonary infection following tuberculosis of the 
uterus and tubes. 
We have recently had a case at this clinic of what 
I considered and diagnosed as tubercular salpingo- 
endometritis. The history is as follows: A. W., 
age twenty-one, married. She is a pale, thin and 
sickly-looking subject. Complains of pains between 24 
the shoulders. Husband decidedly tuberculous. The 
patient coughs a good deal. Appetite poor, bowels 
irregular, tongue and mucosa pale, pulse-beat weak, 
81 to the minute. No bladder symptoms. Sleeps well. 
Menstruated at fourteen, regular, no pain until mar- 
ried at seventeen, shortly after which menstruations 
ceased. First child three years ago, labor normal; 
second child sixteen months ago, precipitated labor, 
post-partum hemorrhage, and retained placenta which 
was removed manually. Since last labor the menses 
have not appeared. There is profuse leucorrhea, pain 
in left ovarian region, the latter rendering the patient 
incapable of doing anything. Examination of chest 
shows the heart to be small, while in both apices of 
the lungs fine crackling rales are heard ; dulness of 
apices on percussion. Examination of the genital 
organs showed a lacerated perineum, uterus auteverted, 
slightly tender and enlarged, and rather bound down 
by adhesions, right adnexa apparently normal, left 
tube about the size of a small sausage and very ten- 
der. 
Since the above notes were taken the patient has 
had a hemoptysis, and the lung symptoms are decid- 
edly worse. In the case of this patient I would not 
like to say whether the tuberculosis of the organs of 
generation were the primary seat of the disease, from 
direct inoculation from the husband, or whether the 
infection was secondary to the lungs. 
As to whether there is a secondary tubercular 
endometritis in phthisical pregnant women, or what 
part it plays in interrupting gestation, I am not pre- 
pared to say; but if it is found consecutively in the 
non-pregnant female, or primarily after conception, it 
appears to me that its existence is a well-founded 
possibility, and the case that I have just related seems 
to bear out this opinion. If it is present during 
pregnancy, 1 think it probable that it would not re- 25 
main without influence in the production of abortion, 
although Lop thinks that tuberculosis does not fatally 
interrupt pregnancy, but that it is a continual menace 
for both mother and fetus. It is of common observa- 
tion that as long as a phthisical woman remains in 
fairly good condition, pregnancy goes to term ; but if 
the affection becomes worse, miscarriage is pretty 
certain to occur. 
Intoxication of the organism is generally admitted 
to be the cause of miscarriage in these cases. As you 
know, Koch's bacillus, although it has been reported 
to have been found in the blood of the living, does not 
often invade this tissue, for I consider the blood as a 
tissue ; it is the toxines secreted by the organism that 
do the harm. That the bacillus of tuberculosis can 
pass from mother to child is an established fact and 
Herrgott, of Nancy, demonstrated the tuberculous vir- 
ulence of the amniotic fluid obtained from a phthisical 
woman. 
The knowledge of the fact that various pathogenic 
organisms can pass from mother to fetus is a great 
scientific conquest, but there are various opinions re- 
garding the part played by the placenta in this process. 
For many authorities, changes in the placenta are 
not considered as essential for the transmission of 
bacteria, and Chambreleut is of this opinion, for in his 
experiments on female rabbits he never found that 
organ pathologically altered, but Malvos believes that 
in order that a mother can directly inoculate the fetus 
with micro-organisms there must be a lesion of the 
placenta, while Schmorl and Birch-Hirschfeld found 
small granulations and Koch's bacilli in the placenta 
of tubercular guinea-pigs. 
Last summer Charrin and Duclert reported a series 
of experiments, showing, on the one hand, that in- 
toxication by the toxines, and, on the other, external 
poisonous material, as lead, mercury or substances de- 26 
rived in certain cases from cellular life (as lactic acid) 
aid the passage of bacteria through the placenta in a 
variable degree. According to these writers, the 
glands which are often excellent fortresses are after a 
time destroyed by the secretions of the bacteria, as, for 
example, the kidneys, the organisms then penetrating, 
going from the capillaries into the tubuli, especially 
after the epithelial structures are deteriorated. And 
they conclude that at present they would say that the 
toxines act more on the cells of the organism than on 
the virus itself. Remy examined the placenta of 
phthisical women who had had premature labors, and 
found their uterine surfaces whitish in color while 
there was a degeneration of the decidual cells. 
Consequently, I think it safe to hold that in some 
cases tubercular endometritis is consecutive to a pul- 
monary infection, and may interrupt a pregnancy as 
well as producing lesions of the placenta, and by this 
means infecting the fetus. 
Lecture III. 
Gentlemen: In this lecture I shall study the 
metritis of infectious diseases as well as that produced 
by intoxications of the economy by lead, mercury, etc. 
The question of infectious metritis is far from being 
settled, as many deny its existence, while others de- 
scribe it as a special and undoubted form. 
Massin used eighteen cases who died from general 
acute infectious processes, such as typhoid fever, re- 
lapsing fever, croupous pneumonia, etc., for the study 
of the pathological changes produced in the uterus by 
these infections. These consisted in a parenchyma- 
tous or interstitial inflammation of the mucosa and an 
interstitial inflammation of the muscular tissue. In all 
there was found an endometritis with hemorrhagic 
foci in the substance and on the surface of the mucosa, 27 
and, according to the writer, the characteristic patho- 
logical change was a considerable afflux of blood to 
the uterus and venous stasis, in other words, the same 
changes as those found in other viscera in general 
acute infectious diseases. In some cases the venous 
stasis was the only thing abnormal, but in others there 
was extreme distention of the vessels with rupture of 
their walls, with resulting severe and numerous hem- 
orrhages into the substance of the mucosa and muscu- 
lar tissue of the uterus. The glands were also in a 
state of parenchymatous inflammation. The inflam- 
mation is sometimes diffuse, at others circumscribed, 
and appears to pass through three stages, namely: 
(a) Exaggerated afflux of blood to the uterus with 
venous stasis and vascular inflammation ; (b) localized 
granular inflammation, consisting of a proliferation of 
round cells around vessels and glands; (c) diffusion 
of the inflammatory state. 
Massin's studies corroborate the writings of Slav- 
janski on the hemorrhagic metritis of cholera; and 
they are so complete that after reading them, I am 
about convinced as to the possible existence of endo- 
metritis in acute infectious diseases. 
I shall now proceed to discuss the question of 
metritis in acute infectious diseases occurring during 
pregnancy, and will begin with measles. When this 
disease'appears in a pregnant woman, it will almost 
always bring about a miscarriage or premature labor. 
Underhill puts it at five times out of seven, while 
Klotz puts it at 75 per cent. The accident occurs at 
the time of the invasion of the disease or during the 
stage of eruption. 
The cause of the interruption of gestation is difficult 
to explain, as the cough and dyspnea accompanying 
this pyrexia cannot be the factor, for the reason that 
there are other diseases, as pertussis, which have 
similar symptoms and in which pregnancy continues 28 
normally. The fever cannot he considered as the 
cause ; the experiments of Doleris and Dore show the 
error of the results given by Kaminsky and Runge, 
so that its action is only accessory, excepting cases in 
which the rise of temperature is sudden and high. 
Likewise it is impossible to admit that the same dis- 
ease in the fetus as in the mother is always the cause 
of miscarriage, for the former is often born without 
showing any signs of the disease 
For Charpentier, maternal toxemia is the cause; 
while for Vinay and others it is due to the action of 
the toxines elaborated by the agents of the infection. 
These toxines act either on the uterine muscle or on 
the nervous system, in the latter case producing con- 
tractions of the uterus. 
Klotz admits that in measles, as in all other eruptive 
fevers, the miscarriage is the result of a simple ex- 
anthemic endometritis, which produces uterine con- 
traction by a reflex action ; a chronic metritis may also 
result. 
Scarlet fever is very infrequent during gestation ; 
but when it does occur, miscarriage is the rule. A 
case is reported by Hervieux, in which the affection 
appeared at the sixth month of pregnancy, and mis- 
carriage took place on the second day of the eruption. 
The same factors have been put forward in scarlet 
fever as in measles; but in the former, death of the 
fetus is far more common. 
Small-pox is one of the most serious complications 
of pregnancy for both mother and child, while vario- 
loid is usually benign, but may give rise to miscarriage. 
Discrete small-pox produces miscarriage in about 50 
per cent, of the cases, while in the confluent form this 
accident occurs in about 80 per cent. It is needless 
for me to say that the hemorrhagic form of this dis- 
ease is usually fatal for both mother and child. Mis- 
carriage occurs at different stages of small-pox, most 29 
often at the end of the eruptive stage when the second- 
ary fever of suppuration takes place. Richardiere, 
who has observed three cases of miscarriage in small- 
pox patients, remarked that this took place during 
the stage of suppuration. Interruption of pregnancy 
depends.on the severity of the disease and also on the 
time of gestation when it appears, the chances of its 
occurrence being far less when pregnancy is not far 
advanced. Death of the fetus is frequent; about 70 
per cent. die. Among the many factors in the pro- 
duction of miscarriage during small-pox I may mention 
fever, medullary lesions, rachialgia, accumulation of 
carbonic acid or oxide of carbon in the blood, etc.; but 
these conditions usually only play a secondary part. 
The generally accepted cause is the infection of the 
maternal and fetal organisms ; on the one hand, it is 
the disease and death of the fetus, while on the other, 
it is the action of the toxines on the uterine muscles 
or on the nervous centre controlling the contractions. 
Other observers believe that miscarriage is due to 
intra-uterine hemorrhages, first described by Pechloir 
and afterwards by Serres, Spiegelberg and others. 
They occur in the decidua, and detach the membranes, 
resulting in the expulsion of the product of conception 
which, according to the given case, will be alive or 
dead. The greater part of modern pathologists deny 
the existence of hemorrhagic metritis in small-pox 
which has been searched for in vain at the autopsy, 
and it is generally believed that the hemorrhage is 
the result of the miscarriage. On this point I have 
little to say, but I do not see why hemorrhagic metritis 
is not possible in the disease under consideration, for 
in one epidemic the disease may not attack the genital 
organs while in another it may. Now, if endometritis 
be admitted as occurring in some cases of small-pox, it 
will be easy to understand the occurrence of metror- 
rhagia in the pregnant and non-preguant woman, as 30 
well as miscarriages taking place during the stage of 
intoxication and its disappearance. A table of 84 
cases of small-pox during pregnancy is given by 
Costet. which shows that in a large number of cases 
miscarriage took place during the period of incubation 
or two months after recovery. 
The pregnant female is not immune to typhoid 
fever, which may occur at any time during gestation. 
This disease produces miscarriage in about 66 per 
cent, of the cases. Sacquin found 199 miscarriages 
out of 310 cases, in other words. 64 per cent. The 
interruption of pregnancy can occur at all periods of 
the disease, but particularly during the second week. 
The products of conception born before the seventh 
month of gestation are generally dead, poisoned by 
the Eberth bacillus, which is transmitted directly from 
the mother, as the experiments of Chantmess and 
Widal have demonstrated. Consequently the most 
frequent cause of miscarriage in this disease is the 
products of secretion and the pathogenic agent itself, 
which act at the same time on the fetus by killing it, 
and on the uterus by producing contractions. But for 
a long time it has been known that typhoid fever can 
produce congestion of the uterus, especially in the 
pregnant state. In the beginning a flooding may ap- 
pear which is quite similar to the frequent symptom 
epistaxis, but later on the hemorrhage is passive in 
character and is made easy on account of the friability 
of the vessels. Duhaut believes that there is a plethora 
of the uterus under these conditions, which may be 
active or passive, and easily producing a detachment of 
the placenta with resulting miscarriage. 
But beside these hemorrhages due to a simple afflux 
of blood, others are met with which are due to a 
primary inflammation of the endometrium; in other 
words, a typical hemorrhagic endometritis. Although 
Gusserow has never met this lesion in typhoid oc- 31 
curring in the pregnant, he nevertheless admits its 
possibility, and states that the cause of hemorrhages 
is to be found in diseases of the endometrium; the 
pseudo-menstruation occurring in typhoid infection is to 
be explained in the same manner. Consequently 
hemorrhagic endometritis in typhoid fever during 
gestation or in the non-pregnant is still an hypothesis 
but has a considerable probability in its favor. 
Cholera has a particularly bad influence on gesta- 
tion, which is interrupted in more than 50 per cent, 
of cases, while women who do not abort during the 
course of this disease, usually die before the uterus 
has had time to empty itself. Death of the fetus 
takes place during the algid state or during the period 
of reaction. The cause of miscarriage in this disease, 
as in all others, has been interpreted in various 
ways. For some, death of the fetus is due to the loss 
of water which produces a decrease in the blood- 
pressure, having for result a diminution in the quantity 
of oxygen in the placental vessels, thus asphyxiating 
the product of conception. Others think that carbonic 
acid is in excess in the blood, which determines pre- 
mature contractions of the uterus, while Queirel be- 
lieves that it is the heavy black blood of the cyanic 
state that deprives the fetus of its normal hematosis. 
According to the modern bacteriological researches, 
miscarriage in cholera, as in all other infectious dis- 
eases, is. the result of intoxication of the maternal and 
fetal circulation by the bacillus of the disease, as well 
as its toxine. The well-known theory of Slavjanski 
should also be borne in mind. This observer, struck 
with the frequency of uterine hemorrhages during 
cholera, examined the cases in order to ascertain if 
these floodings were not a Symptom of a pathological 
change, and the result was that he nearly always 
found lesions of the uterus. The decidua vera was 
very thick, soft and of a dark-violet color, and hem- 32 
orrhagic foci, measuring as much as a centimetre and 
a half in diameter, were found in its substance. The 
decidua refiexa was also thick, but less so than the 
vera, and offered a few hemorrhagic foci not larger 
than millet seeds. 
In pregnant women with cholera these changes are 
the cause of miscarriage, while in the non-pregnant, 
they cause hemorrhages. Let me add that this opinion 
has been attacked by many observers, particularly by 
Queirel, who never found a hemorrhagic endometritis 
in all his necropsies. However, these conscientious 
researches of Slavjanski remain as most instructive, 
and allow us, I think, to often attribute an abortion 
in cholera to hemorrhagic endometritis. 
The action of influenza on the female genital or- 
gans is undoubted. In 1890, Muller gave statistics of 
51 cases from which he concluded that this disease 
may produce metrorrhagia in the non-pregnant, char- 
acterized by its long duration and obstinacy to the 
usual therapeutic measures, while in the pregnant, 
miscarriage results. The experience of many others 
corroborates this view, and it is certain that the fre- 
quency of miscarriage and premature labor varies ac- 
cording to the severity of the epidemic. A third of 
Vinay's cases had a premature labor, and this is the 
result of the observations of others. 
If, in other acute infectious diseases, the hypothesis 
of endometritis as a cause of miscarriage is attacked, 
there is certainly much reserve to be made in the 
case of influenza. According to Labadie-Lagrave, 
the hemorrhages in influenza are well explained by an 
acute inflammation of the mucosa; and what is more, 
taking into consideration the well-known influence of 
endometritis on miscarriage, the idea of an infection 
of the mucosa explains the occurrence of abortion and 
premature labor during la grippe. He thinks that it 
is difficult to admit a secondary infection, and believes 33 
that it is more in keeping to attribute the cause to the 
pathogenic agent of la grippe itself. Vinay also be- 
lieves in an inflammation of the decidua, but this 
lesion is far from being constant. 
It is also quite possible that the specific bacteria 
produces a toxine which acts on the nervous centres or 
on the muscular fibres of the uterus; but if we find 
ourselves in presence of characteristic uterine symp- 
toms, I believe we should attribute the miscarriage or 
premature labor, as the case may be, to an infectious 
endometritis, and if there are hemorrhages before the 
beginning of any symptom of labor, it is most prob- 
able, as is argued by Vinay, that there is an endo- 
metritis of the decidua. 
Gottschalk examined the endometrium of a number 
of patients having metrorrhagia, and always found it 
inflamed and in a state of desquamation; and, accord- 
ing to this observer, the specific organism of influenza 
acts in the genital tract in the same manner as the 
gonococcus. 
I have, gentlemen, studied with you , the infectious 
diseases in which endometritis has been considered by 
many as the factor in the production of miscarriage, 
and perhaps it also plays a kind of part in other in- 
fectious maladies. It is very probable that sudamina (?) 
may produce metrorrhagia and deviation in the menses 
and miscarriage. As to lobar pneumonia, which is 
certainly a typical infectious disease, and which is 
sometimes accompanied by metrorrhagia according to 
Flatte, I have little to say. I have personally at- 
tended two pregnant women in this disease, and in 
neither was there any flooding during their illness; 
but in both, strange to relate, miscarriage occurred. 
In one it was six weeks after recovery ; in the second, 
nearly two months after. Whether the interruption 
of gestation was due to the infectious process or not, 
I am not prepared to say. 34 
You see, gentlemen, that acute infectious processes, 
especially certain ones, act directly on the uterine 
mucosa of pregnant women, and that this endometritis 
may cause miscarriage, the most frequently by hem- 
orrhage, with resulting detachment of the ovum ; but, 
as I have already remarked, I do not believe that an 
inflammation of the mucosa necessarily is present in 
every case of infectious disease and produces miscar- 
riage. 
The pathology of the latter depends on different 
conditions, such as the particular form taken by the 
given epidemic, the severity of the disease, the general 
conditions of the woman, and perhaps the manner of 
infection. It is impossible to attribute each and every 
miscarriage occurring during an infectious disease to 
the same mechanism or to the same agent producing 
the given infection. 
In taking into consideration the modern theories of 
infection, we must remember a point often forgotten, 
namely, that infection of the organism may produce 
miscarriage, not only by the action of the bacteria 
and their toxines on the nervous centres or the mus- 
cular tissue of the uterus or the fetus itself, but also 
by their action on the cells of the uterine mucosa, 
producing the phenomena of inflammation. 
As to intoxications by lead, mercury, sulphide of 
carbon, etc., their effects have long been known, but 
their manner of action is far from being understood, 
Of the intoxication by lead, or saturnism, I will say a 
few words. In 1860 Constantin Paul called attention 
to the influence of lead-intoxication of the parents on 
the product of conception, showing that it demonstrated 
its effects in many cases by death of the fetus and 
miscarriage; and out of 123 pregnancies he found 64 
miscarriages. This fact is explained by the intoxica- 
tion and death of the fetus on the one band, while on 35 
the other, we have the action of the metal on the 
uterus. But beside these causes, which are the most 
frequent, it is also a fact that an endometritis may 
develop under the influence of saturnism. Cases have 
been reported of women suffering from lead-intoxica- 
tion who presented typical symptoms of an endo- 
metritis during pregnancy, the child being born alive ; 
the membranes were thickened, the placenta hyper- 
trophied, etc. 
A case occurred in the service of Professor Tarnier, 
of a woman suffering from saturnism, who had in all 
probability an endometritis of pregnancy. She was 
delivered at the seventh month of a living child 
weighing 1,340 grammes, while the placenta weighed 
480 grammes. 
If the hypothesis of endometritis produced by sat- 
urnism be admitted, it would be easy to explain the 
metrorrhagia and sterility which result. However, I 
will not take your time in further argument of this 
question ; but let me, in terminating this lecture, say 
that women who are employed in rubber manufactories, 
where sulphide of carbon is employed in the prepara- 
tion of the goods, miscarry often, and sterility is 
frequent. 
Lecture IV. 
Gentlemen : In this lecture I propose to finish the 
subject of metritis as a cause of miscarriage; and in 
order to do so, I must consider the following points: 
the course of pregnancy complicated by metritis or 
endometritis, the mechanism of these abortions, the 
diagnosis, prognosis and treatment. 
It is in no way a general rule that the symptoms of 
an endometritis are present during gestation. Some- 
times the progress is perfectly normal aud the preg- 36 
nancy goes to term, and it is only after labor that 
the inflammatory changes are found in the placenta 
and membranes. 
Pregnancy may go on undisturbed for a few months, 
when suddenly pains and hemorrhage appear, quickly 
followed by an abortion ; in this case it is the decidua 
that will give a clue to the cause of the miscarriage. 
Generally speaking, endometritis of pregnancy will 
show its presence by various symptoms, these being 
principally the same as those of an endometritis of the 
iion-pregnant organ, only they are more marked in 
the former. They differ according to the extent of 
the lesions of the mucosa and time of pregnancy at 
which they occur. Those that take place during the 
first six months will only be studied. 
The most important and constant symptom is hem- 
orrhage. Its origin is most varied. Usually when 
the vessels of the decidua serotina are inflamed, they 
become friable and rupture easily, thus bringing about 
a partial detachment of the placenta, while the blood, 
breaking its way between the decidua and wall of the 
uterus, appears. 
If the inflammation of the mucosa is slight, the hem- 
orrhage may be trifling and of short duration, without 
any symptoms, so that the patient pays little attention 
to it; but when the endometritis is more severe, hem- 
orrhage is provoked by very slight causes, which iu 
the healthy woman would be without effect, and they 
will persist or stop for a short time only to commence 
on the slightest occasion. The other symptoms are 
not long in showing themselves. 
The blood of these hemorrhages is sometimes 
bright red and pure, but generally it is mixed with a 
watery fluid and vaginal or uterine secretions. Sudden 
and severe hemorrhage may occur, bringing about mis- 
carriage more or less rapidly. This takes place iu 37 
endometritis following acute infections such as cholera, 
typhoid, small-pox, etc.; or they may occur in cases 
of old hemorrhagic metritis. 
Leucorrhea is a nearly constant symptom. It may 
be overshadowed by the blood, but it exists here iu 
some way or another, just the same as in a metritis in 
the non-gravid uterus. In passing, let me recall to 
your minds that leucorrhea is the exaggeration and 
morbid change of the normal secretion of the uterus. 
Leaving aside the description of the watery, milky- 
colored vaginal leucorrhea, which has nothing to do 
with our subject, because it is the uterus that is af- 
fected, I shall simply describe the discharge from this 
organ. When it comes from the corpus it is a whitish- 
yellow and thick, while that from the cervix is usually 
gelatinous and whitish-yellow, sometimes greenish- 
yellow, and purulent, with an alkaline reaction. Oc- 
casionally the secretion from the cervix is only a 
liquid mucus, containing a few leucocytes; while in 
other specimens, although it may be viscid and trans- 
parent, it is, nevertheless, virulent, and may contaiu 
gonococci. Leucorrhea varies greatly as to quantity, 
and is generally not continuous. I do not mean that 
the secretion is not constant, but the product of this 
secretion is only evacuated at intervals. It accumu- 
lates first in the vagina, and escapes from time to time 
in small quantity from the vulva. 
Hydrorrhea is a colorless liquid discharge; it is 
clear, slightly viscid, sometimes tinted pink, and of a 
gummy consistency. The spots produced by this dis- 
charge are sometimes almost invisible, at others they 
are pinkish with a darker border. The principal 
characteristic of hydrorrhea is its manner of appear- 
ing which is by a sudden profuse flooding of watery 
fluid coming on without any apparent cause. When 
the quantity exceeds 300 grammes, the hydrorrhea 38 
may be preceded by an increase in the size of the 
uterus, which is discovered by palpation, and the pa- 
tient may also complain of a sensation of tension and 
weight, which will disappear after the liquid has come 
away. 
This discharge from the genital organs, which 
usually appears in the midst of apparently perfect 
health, may not occur again, and does not produce 
any serious trouble. However, it is not uncommon 
for the discharge to appear at irregular or regular in- 
tervals. Sometimes the floodings succeed one another 
with increasing frequency; at others they come on at 
intervals farther and farther apart. The quantity of 
the discharge varies in different cases, increases or 
diminishes. Between the intermittent jets there is 
usually no discharge, although this is not always so. 
In a case reported by Roy the hydrorrhea was first 
colorless and then became bloody, appearing at ratlur 
long intervals for two months and a half. In a case 
reported by Zielinski, the patient had four watery dis- 
charges, which were preceded by lumbar and abdom- 
inal pains ; this discharge became pink and later red. 
Pains may accompany the above symptoms, or come 
on alone, being the only symptom of an inflammation 
of the mucosa. Their type varies. If they accom- 
pany a slight hemorrhage, they do not amount to 
much ; but if they occur during a serious flooding, they 
are intense and increase as the time of expulsion ap- 
proaches. 
Ordinarily, hydrorrhea is accompanied by a malaise 
and disagreeable sensations in the pelvis. The ac- 
companying pains vary in different subjects, accord- 
ing to the susceptibility of the nervous system. The 
subjective symptoms are sometimes so slight as to pass 
unnoticed; at others they are marked by continu- 
ous or intermittent pains in the pelvis and hypogastric 39 
regions, extending down towards the sacrum and upper 
part of the thighs. When severe, the subject has 
difficulty in walking, etc. 
The origin of the pains is in the uterus, but their 
seat may, be in different parts of the body. The 
hypothetical rheumatism of the uterus has also been 
put forward to explain the pain. 
It is impossible to diagnose the type of endometritis 
from the character and seat of the pain ; and it is 
likewise difficult to explain the cause, although Veit 
thinks that perhaps they might be attributed to small 
hemorrhages in the decidua which are slowly under- 
going resorption, as well as to small inflammatory foci. 
Endometritis may finally produce a rupture of the 
membranes, because the inflammation of the decidua 
causes the chorion and amnios to become so thin and 
friable that when even a slight traumatism is inflicted, 
such as a little jar, going from one room to another, 
it may result in their rupture. Other symptoms of 
endometritis often precede the rupture of the mem- 
branes, although exceptionally, this accident is the 
first indication of the disease. 
Now, if you examine the uterus of a pregnant 
woman with endometritis, you will generally not find 
any distinct signs. Frequently its size does not cor- 
respond to the age of pregnancy; it will be larger. 
Sometimes it changes in dimensions; for example, 
after the liquid of an hydrorrhea has been expelled, 
it decreases, and the walls which were distended be- 
come soft and are easier to palpate. Per vaginam, 
the lower segment of the organ may perhaps be found 
thickened and inflamed, rendering the fetal parts im- 
perceptible to the examining finger. Palpation or 
vaginal examination may cause considerable pain for 
the patient, the least pressure on the abdomen, cervix 
or inferior segment of the uterus produces suffering. 40 
By the speculum, beside erosions, lacerations, etc., 
you will sometimes be able to see characteristic ulcera- 
tions having a fungoid appearance and a crater-like 
depression. These lesions alone, which were present 
before pregnancy, are a danger, not directly in them- 
selves, but because they are often the indication of 
similar inflammatory lesions in the corpus uteri. 
As parenchymatous metritis is very often accom- 
panied by an endometritis, the symptoms of the in- 
flamed mucosa may often be present. On the other 
hand, if the parenchymatous metritis is of long stand- 
ing, the endometritis may have disappeared and left 
behind only such traces as partial sclerosis or a few 
indurated points. In this case the leucorrhea, hydror- 
rhea and hemorrhage may be wanting. There is one 
symptom, however, which is never absent, and that is 
pain. This may be more severe than in any other 
type of metritis, and is explained by the extreme dis- 
tention of the uterus. 
By a very careful examination of the uterus per 
vaginam you may sometimes feel an induration of the 
walls of the organ; but, I repeat, this condition is 
rarely discovered. 
The most characteristic symptom of an inflamma- 
tory condition of the mucosa is to be found in the 
antecedents of the patient when she tells you that she 
often aborts and that the accident usually takes place 
at about the same period of gestation. 
The progress of a miscarriage due to an endome- 
tritis is about the same as in miscarriage from any 
other cause. 
There are two signs worth remembering, to which I 
wish to call your attention. In the case of a fetus di- 
rectly poisoned by the specific organism and toxines 
of any of the acute infectious diseases, it first dies and 
is then expelled, while in endometritis it is expelled 41 
alive in the larger number of cases. There are, of 
course, many exceptions, and I have pointed out to 
you that a diseased decidua will produce nutritive 
troubles in the ovum resulting in its death. 
Another sign of miscarriage produced by endome- 
tritis is the retention of the placenta and membranes. 
This may occur in any abortion, especially those which 
take place during the third and fourth months, be- 
cause the connections between the uterus and placental 
tissues are intimate. But if the decidua is inflamed, 
in which case many of the glands are destroyed and 
their place occupied by connective or even fibrous 
tissue, adhesion of the membranes and placenta are 
quite frequent. 
The latter organ is only infrequently completely ad- 
herent, but if so, it may be retained in the uterine 
cavity for many months without giving rise to any 
symptoms. It finally undergoes a granulo-fatty de- 
generation, then sclerosis, and is at last spontaneously 
or artificially delivered. 
Partial adhesion is far more frequent. Sometimes 
the placenta is partly detached and partly adherent, in 
which case two of the most serious complications 
occur, namely, hemorrhage and septicemia. At other 
times the placenta is only partly expelled, and the re- 
maining part is found adhering to the uterine walls. 
This latter may be quite considerable in extent and 
give rise to no symptom up to the time that it is ex- 
pelled, but when it becomes detached hemorrhages are 
wont to appear. 
In other cases you may have a very small piece of 
placenta adhering intimately to the walls, and this may 
also remain for a relatively long period in the uterine 
cavity. This very adherent placental debris may pro- 
duce hemorrhages which are sometimes most serious, 
and have been denominated deciduoma. 42 
The diagnosis of puerperal endometritis is in most 
cases very difficult to make, and the only positive 
pathological sign is an inflammation of the decidua. 
It consequently is only after abortion has taken place 
that the diagnosis is made ; but in some cases shreds 
of the decidua are expelled, and after a microscopical 
examination the inflammatory process going on in 
utero may be suspected. 
But unfortunately these favorable cases for diagno- 
sis are infrequent, and you will have to content your- 
selves with the symptoms which are far from being 
characteristic. Consequently you should proceed to 
make a differential diagnosis in a most careful man- 
ner. 
, In the first place the patient's antecedents regarding 
the menses, pregnancies, labors and post-partum period 
should be carefully inquired into, as you know the 
great value of some knowledge on these points; and 
especially is this true in cases of endometritis. If you 
find that the former pregnancies were interrupted, if 
the labors were complicated by placenta previa or re- 
tention of the afterbirth, if the decidua was thick, all 
these facts will help you in your diagnosis, because 
they all cau be produced by an endometritis. 
Now, if you learn that your patient was infected 
during her last labor, or post-partum, or if she has 
gonorrhea, syphilis, or an acute infectious process, if 
she has suffered for some time with a metritis, why 
then your diagnosis becomes easier to make. 
It now remains for me to say a few words regarding 
the actual symptoms of the affection. Intermittent 
hemorrhages produced bv a slight cause are to be 
especially noted ; their particular point is their repeti- 
tion for several weeks before miscarriage up to the 
time this takes place. But you must not forget that 
you may have to deal with some heart lesions, fibroids 43 
or cancer of the uterus or cervix, varicosed veins of 
the external genitals, placenta previa, albuminuria, 
traumatism, etc., all of which may have hemorrhage 
for a symptom ; and you must eliminate these. You 
should always examine the general health of a preg- 
nant woman, the condition of all her viscera, and 
above all, the internal and external genital organs, not 
forgetting to examine the odor of the blood passed (if 
this occurs) as well as the quantity and frequency. 
Leucorrhea which is very common, must be exam- 
ined to ascertain if it be vaginal or uterine; in the 
latter case if it comes from the corpus or cervix, or if 
it is simply due to a defect in the general nutrition 
from anemia or chlorosis. 
A watery discharge should be carefully looked to, 
as its origin is most important to ascertain. Do not 
forget that a thin watery and nearly odorless discharge 
may be due to a commencing carcinoma uteri. 
If it is the amniotic fluid and if the ovum has rup- 
tured, the walls of the uterus will be found retracted 
on the fetus, which will be slightly immovable on ac- 
count of this pressure. An iutra-cervical digital ex- 
amination, by displacing the fetus, will give rise to the 
appearance of a serous liquid in which lanugo and 
sebaceous magna will be found ; the liquid will trickle 
away slowly but continuously. 
The characters of decidual hydrorrhea are different 
in every respect; the amniotic pouch is closed and in 
spite of the watery discharge distinct ballottement 
can be produced. Occasionally the discharge is only 
an involuntary emission of urine or the elimination of 
leucorrhea which has accumulated in the vagina; but 
here the nature and odor of the liquid is quite sufficient 
to prevent an error in diagnosis. 
You must be guarded in your opinion as to the 
pains which will be complained of by your patients, 44 
because the description given is usually far from clear. 
Women usually give you the impression that they are 
suffering from nephritic or hepatic colic, gastralgia, 
cancer or neuralgia; so I again warn you not to base 
your diagnosis on the symptom of pain alone, for gen- 
erally you will be terribly deceived. Do not forget 
to note whether the pains are accompanied by uterine 
contractions, thus announcing approaching labor. 
Let me impress upon you the fact that not one symp- 
tom taken alone will justify you to make a diagnosis; 
it is only when you have all the symptoms, plus a his- 
tory of the last pregnancy and antecedents of the patient, 
that you can feel that you have a rather complete 
picture of puerperal endometritis. 
The prognosis for the mother in this form of en- 
dometritis, depends on her general condition, the 
severity of the disease and its cause. You will easily 
understand that the hemorrhagic variety, which is en- 
countered in the acute infectious diseases, is far more 
serious than old chronic endometritis with its slight 
losses of blood or watery discharges, which have little 
effect on the health of the woman. As a matter of 
fact there is a great difference in the prognosis of an 
inflammation of the mucosa in a strong healthy woman 
and a subject already exhausted from chlorosis or 
tuberculosis. 
You should always have in mind two possible com- 
plications, namely, aute-partum hemorrhage and the 
retention of the membranes or placenta. The hem- 
orrhage may be so considerable as to endanger the 
life of the patient and the blood is sometimes so fluid 
that it flows in great quantity, while in other cases clots 
form and accumulate in the vagina, acting like a 
tamponade.. 
A hemorrhage, as you are aware, gives rise to quite 
marked general symptoms, pallor of the teguments, 45 
small bounding pulse, tinnitus aurium, troubles of sight, 
etc., while there is also often a tendency to syncope. 
A retention of the membranes or placenta will also 
render your prognosis more sombre, because this con- 
dition may be the cause of a post-partum hemorrhage 
or even septicemia. 
A post-partum hemorrhage is either continuous or 
intermittent, profuse or slight. It takes place soon 
after the expulsion of the product of conception, but 
may, although infrequently, occur from ten to thirty- 
five hours after. In the first instance it is produced on 
account of the retained debris preventing the uterus 
from firmly contracting upon itself; while in the 
second it is due to the tardy detachment of the re- 
tained mass, which leaves the uterine vessels largely 
opened. This loss of blood is not always an immediate 
danger for the patient, but it produces a most serious 
anemia, which will only be overcome by a long and 
well-directed medical treatment and cleaning the 
uterus out. 
Septicemia comes on a short time after if abortion oc- 
curs, as the uterus remains half opened for the exit of 
blood, and the infection is thus able to have easy ac- 
cess to the interior of the organ. If the placenta is 
partially detached, thus having its blood-supply in 
part cut off, putrefaction takes place from the contact 
of air, and it consequently becomes a source of infec- 
tion. Septicemia is often produced by unclean hands 
employed in a vaginal examination, or by faulty 
asepsis of instruments, dressings, etc. 
Septicemia will very often leave behind serious 
lesions of the uterus or adnexa. Do not forget this ; 
and if you have the misfortune to treat a case of this 
kind, do your work thoroughly, and in so doing you 
will probably prevent a salpingitis and peritonitis. 
Occasionally the fever persists, the chills come 46 
back, and the patient dies from the progress of a 
putrid infection; but there are also cases in which the 
symptoms of auto-infection suddenly disappear after a 
spontaneous or instrumental elimination of the placental 
debris. 
When the membranes alone are retained, hemor- 
rhage and infection are far more infrequent. 
The retained remains of the placenta or decidua ad- 
hering to the uterine walls may enter into the forma- 
tion of a deciduoma, which is a source of very severe 
hemorrhages. Kiistner states that a retained decidua 
and chorion may give rise to a malignant deciduoma, 
which statement has been corroborated by Move- 
Josseraud, Lacroix, and Jeannel and Bacon. 
As to the treatment, I may say at once that it is 
very difficult to treat an endometritis as long as preg- 
nancy is going on. The only good practice is the 
preventive treatment which is undertaken when the 
uterine cavity is empty in cases in which an inflamma- 
tion of the uterine mucosa has occurred before the 
pregnancy or when it has already produced miscar- 
riages. 
There are to-day many recorded cases of women 
who had aborted several times and who became preg- 
nant after a cure of the endometritis had been ob- 
tained, and went normally to term. 
The treatment applied to endometritis has been 
most varied, but there is no doubt but that a well-con- 
ducted curettement of the uterine cavity is the best 
and most proper method. It is generally accepted 
that after removal of the mucosa by the curette, this 
will be reproduced in such a way that a normal con- 
ception and pregnancy will take place; but it is diffi- 
cult to indicate with certainty at what time the endo- 
metrium will have become really apt for this new 
function. 47 
It is generally believed that the first menses after 
curettement is a proof of a cure of the endometritis 
and as indicating the presence of a healthy mucosa. 
There are, however, cases which plainly show that al- 
though all symptoms of inflammation of the mucosa 
have disappeared and the menses are normal, the en- 
dometrium is not in a condition which will allow the 
ovum to develop. 
When the endometritis is dependent on a general 
infection, a general treatment must be instituted ; for 
example, mercury in syphilis. 
Preventive treatment is often crowded by success in 
cases of parenchymatous metritis; but here curette- 
ment is rarely indicated, and will do little, if any, good 
when performed. If there are indurations in the walls 
of the uterus which are due to old inflammatory ex- 
udation, I would strongly advise a course of massage, 
which will give most excellent results; but on the 
condition that it is properly and scientifically done. 
Those of you who are desirous of possessing an idea 
of the technique of massage of the female genital or- 
gans will do well to read my translation of two lectures 
on the subject by my esteemed teacher, Professor 
Vulliet, and which was published in the Annals of Gyn- 
aecology and Pcediatry in 1890. 
When you are in presence of a hemorrhage or 
uterine pains, the preventive treatment of abortion in 
general should be the one of choice. This consists of 
a quiet in bed, enemas of laudanum or chloral hydrate, 
hyperdermic injections of morphine, etc. But if 
abortion is threatening, you must not hesitate to act 
immediately ; and for the hemorrhage a well-applied 
vaginal tamponade, with iodoform gauze, should be 
practised. 
Now, if miscarriage is inevitable, either because the 
death of the fetus is certain or because the membranes 48 
have ruptured, you should not delay the expulsion of 
the ovum. All that is necessary under the circum- 
stances is to irrigate the vagina thoroughly with a one- 
per-cent. solution of sulpho-naphthol or some other 
good antiseptic, and have before your minds that a 
miscarriage demands more strict antisepsis and more 
care than a normal labor. 
When the placenta or membranes are retained, I 
think it advisable to remove them with a dull Khein- 
stmdter curette, but do not forget that the walls of the 
uterus after labor are thin and easily-yes, very eas- 
ily -perforated by your instrument, a complication 
that you all want to avoid. After you have removed 
the retained debris, a hot intra-uterine irrigation 
should be given, and the cavity packed with iodoform 
or europhen gauze.  THE BOSTON - 
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