NON - INFECTIVE ENDONIETRITIS.—Under this heading we may group a number of conditions in which the presence of an infective agent is either not suggested or not proven, and to which the title of an inflammatory condition suggested by the name " endometritis " can only be applied by courtesy. They may be divided into the following groups: r. Conditions Associated with Hypertrophy of the Endometrium .—These include cases of retroversion with enlargement of the uterus. cases of slight subinvolution of the uterus after abortion or childbirth (often due to the retention of some part of the secundines), cases of " glandular," " interstitial," and " polypoid " endometritis, and are marked by a leucorrhceal discharge with sacral weight and pain, some dysmenorrhoea and menorrhagia. General hygienic treatment, with the administration of iron, should be tried first in these cases. Local treatment on the lines mentioned under chronic endometritis should accompany it, but is not as a rule very satisfactory. Curetting is more successful, and curetting followed by local treatment is most successful of all.
2. Conditions Associated with Atrophy of the Endometrium.—As a rule the most marked symptom in this class of case is menstrua tion becoming both irregular and profuse. A few cases of menorrhagia in young women belong to this type, most cases of menstrual irregularity due to the presence of a submucous fibroid, and lastly many cases of irregular losses in the decade from 4o to 5o years of age. It is especially in regard to this last type of case that a word of warning should be uttered. There can be no objection, except that attaching to the probable failure of the treatment, to a practitioner endeavouring to cure a case of menorrhagia in a young woman by general or local tonics such as Iron, Ergot, Viburnum Prunifolium, Styptol, or the like. On the other hand, when a woman above 4o years of age consults a doctor for uterine hemorrhage he is acting in defiance of the patient's interests and of his own if he pre scribes for her before he has excluded uterine cancer as the possible cause of the bleeding. Every physician knows that the only hope of cure in
cancer lies in the complete removal of the tumour by operation. Every day during which the tumour is allowed to grow lessens the probability of a complete removal and makes the hope of cure more slender. It is therefore the bounden duty of the doctor to make the diagnosis certain and absolute at the earliest possible moment. No considerations should be allowed to postpone a vaginal examination both with the finger and the speculum, and it nothing is discovered the investigation should not end there. As soon as possible the uterus should be curetted and the fragments examined microscopically by a competent pathologist in order to exclude the possibility of a corporeal cancer. Few patients will refuse to submit to this thorough examination when the importance of it is explained to them, and the assurance may be given that if no serious mischief is present the operation will completely relieve the symptom on account of which advice was sought.
Curettage.—This operation has been frequently mentioned in connec tion with the treatment of endometritis. It is indicated in cases which resist a thorough trial of local and constitutional therapy or which are improved by it only to relapse. It may be safely recommended when the main symptom is menorrhagia, where the uterus is bulky and rather tender, and when leucorrhceal discharge persists in spite of treatment. It is contra-indicated in all cases of active inflammation of the uterus, and in cases of inflammation of the ovaries and tubes, especially when signs of a collection of pus (pyosalpinx or ovarian abscess) are present. Before performing the operation the possibility of pregnancy should be excluded, and in many cases the operation should be looked upon as merely inaugurating a course of local (by tampons, douche, &e.) and constitutional (tonic and hygienic) treatment, which may be pursued with better hope of success after curetting.