discharge diminishes, and within a week she is able to be up. This happy result is not often seen in untreated cases, and in those cases which do recover without complication, the inflammation usually persists as a chronic process.

Differential Diagnosis.-There is usually a history of traumatism, such as an operation or invasion of the inside of the uterus or of abortion or labor. This is lacking in gonorrhea. Again, in gonorrhea there is to be found usually some other manifestation of that disease, as urethritis or Bartholinitis, or vulvitis. Endocervicitis does not present the grave symptoms which are due to endometritis. Acute tubal and ovarian inflammation and peritonitis give signs in the peri-uterine tissues which are not found with uncomplicated endometritis.

Sequela.—The most common sequela of a neglected septic endometritis in a nulliparous uterus is salpingitis. The peritoneum may become involved, and from this point the infection may spread so as to implicate the ovaries and general pelvic peritoneum. The uterus may be retroposed or become so, and will become adherent in its displaced position.

Treatment.-NON-OPERATIVE.-If the condition follows a septic plastic operation, all sutures should at once be removed and the wound painted with tincture of iodin. No vaginal dressing should be applied, but the freest possible exit to the pus afforded. Warm vaginal douches of one-half of one per cent. lysol or three per cent. boric acid are to be used every three hours. Attempts should always be made to wash out the uterus. The ease with which this may be done is dependent upon the state of the cervical canal. The patient is placed in Sims' position and the perineum drawn back. The operator and his material are sterilized (see sterilization). The cervix is sterilized by means of an application of iodin (see endocervicitis), steadied by a pair of blunt bullet forceps, and the direction of the uterine canal found by a sound. A Fritsch-Bozeman catheter to suit the size of the cervical canal is then introduced up to the fundus (Fig. 9). No vio

33

lence is to be used. The irrigator (see sterilization) should be five feet above the patient. At first a quart of Thiersch solution is allowed to flow through the catheter, to be followed by at least four quarts of a three per cent. solution of boric acid crystals. The treatment varies according to the progress of the case. Often one such washing will suffice to subdue acute symptoms; but, if after waiting twelve hours, the patient is not markedly better, the washing is to be repeated. The irrigations are to be made once or twice daily, the physician being governed by the amount of discharge and the symptoms. An ice-bag should be worn over the pubes continuously until convalescence begins. The sense of weight and even the inflammation are materially lessened by local bloodletting. This is done by superficial stabs into the cervix with a bistoury.

After the acute symptoms subside, the case is to be treated as are cases of chronic endometritis. The pain is sometimes unbearable. In vigorous individuals phenacetin, grs. v, with codein, gr. ss., may be administered and repeated in two hours if needed. Or a rectal suppository of extract of opium and ext. belladonna, each gr. ss., may be given. But in administering these drugs the sympt ms are so masked that the extension of the disease may not be appreciated, and it is therefore advisable to avoid them. It is not necessary to purge these patients; merely normal stools are all that are required. The rectum must be kept empty.

If after two days' treatment the local and general symptoms do not improve, an extension to the adnexa or peritoneum is to be suspected. During the treatment, light vaginal tampons of iodoform gauze may be used instead of the douches, where the uterus is subjected to jarring by vomiting.

SURGICAL TREATMENT.-In view of the possible extension of the infection to the peritoneum and adnexa, it is important to check the disease at once. This can be done with certainty by a properly performed curettage (see curettage). The responsibility resting upon the at

tendant is so great that he should in all cases place himself clearly on record with his patient and compel her to assume responsibility for any complication which may follow a neglect to clean out an infected uterus. If the curettage has been improperly performed or done too late to check an extension to the tubes and peritoneum, it will be necessary to open the cul-de-sac and treat the adnexa (see cul-de-sac operation).

PUERPERAL INFECTION.

This is an infection occurring during the first four weeks after delivery. Infection ensuing after that time is not puerperal infection, but is merely endometritis in a large uterus; and treatment applied to an infected uterus after the puerperal month is not the treatment of a puerperal uterus, although the lesions may be the result of a puerperal infection. Therefore, curettage or hysterectomy done some six weeks after delivery is not to be considered as having been applied for puerperal fever. The condition of the tissues one week and six weeks after labor are so different that the lesions produced are different, and the dangers from a hysterectomy at the two intervals are about as fifty per cent. to five per cent. Infection after abortion is similar to that after labor. But the smaller uterus with its less active lymphatics and vessels, when infected, produces less septicæmia. The gravity of the symptoms is usually in direct ratio to the period of gestation. The infections after early abortions, as at the fourth week, take on the type of endometritis. The later abortions assume the characteristics of infection at full term. The line cannot be sharply drawn between those cases to be classed purely as abortions and those which shall be called puerperal.

It is eminently proper that I describe in a separate chapter the forms of infection occurring during the puerperium. More especially am I prompted to do this because the method of treatment I employ is somewhat different from that of most surgeons and because these