the hypoplastic type, and differed widely from the case of foetal bone disease which he (Dr Ballantyne) had shown to the Society in 1889, and in which the cartilage of the ends of the long bones showed enormous hypertrophy.

V. Dr Church showed a GARMENT which he had designed for the treatment of masturbation in a young girl. It had been successful.

VI. Dr Angus Macdonald showed for Dr Brewis-(a.) A DERMOID TUMOUR OF LEFT OVARY, removed successfully by abdominal section from a lady of 72. The tumour was in a semi-gangrenous condition, with hemorrhage into its substance, and the pedicle was found to be twisted through two complete turns. The patient had recently had several severe attacks of local peritonitis.

(b.) RIGHT-SIDED APPENDAGES, showing unusual cystic dilatation and presence of bony mass-probably a dermoid tumour of ovary. Appendages of other side in similar condition, but not removed. (c, d.) Two other typical DERMOID TUMOURS,

(e.) Right and left cystic OVARIAN TUMOURS, showing extensive degenerative changes (myxo-sarcomatous ?). Patient made excellent recovery after removal by abdominal section.

(f.) APPENDAGES removed for FIBROID UTERUS: one ovary showing small pediculated fibroid.

VII. SENILE UTERINE CATARRH.

By J. HALLIDAY CROOM, M.D., F.R.C.P.Ed., Physician to, and Clinical Lecturer on Diseases of Women, Royal Infirmary, Edinburgh.

THE Condition which I propose shortly to discuss is one which is much more frequently met with in private than in hospital practice. Indeed, I can scarcely say that I have met with a typical case in hospital. This is easily explained, as the symptoms, though troublesome, are not severe, and the poorer classes do not seek relief except under circumstances which are more or less urgent.

The subject of endometritis occurring in old women, or rather in women who have for some years passed the menopause, is but meagerly if at all described in any of the text-books-not even in the more recent ones. Various monographs have, however, been written on the subject, and the condition described under various titles. Thus, some have called it the 'fœtid endometritis of old women,' others' post-climacteric endometritis.' Matthews Duncan described it under the name of the 'leucorrhoea of old women.' But I am inclined to think that the term which best describes the group of symptoms is' senile uterine catarrh.'

With the ordinary uterine catarrh of fertile women everyone is familiar, due to the condition of subacute endometritis, and one of

the most frequent causes of sterility. The importance, however, of the condition occurring after the climacteric cannot be questioned, and I am sure that a due appreciation of it would save many an unfortunate woman from vaginal hysterectomy, which, with improved methods and increased safety, is too apt to be had recourse to without adequate reason.

It is well known that the great difficulty in the management of such cases is the differential diagnosis from malignant disease, but it seems to be that this is exaggerated, and that with due care and no unnecessary haste an accurate diagnosis can be made in the majority of cases.

Sexton, in an admirable paper on 'post-climacteric endometritis,' advocates the use of this term, because most appear soon after the menopause. With this I entirely agree. However, while most do come under observation soon after menstruation has ceased, in my experience a large number seek advice many years after the climacteric, and these are the most marked cases, although the most difficult to diagnose.

Before going further, and without multiplying cases, let me give three typical examples :

CASE I-A patient, æt. 70, complained of a fœtid muco-purulent discharge, accompanied by constant pain in the back, with occasional and irregular attacks of colicky pain in the pelvis, but there was no hæmorrhage whatever. She was pale, sallow, and emaciated. The uterus was about 2 in. long, retroverted and mobile. The os was somewhat gaping. Her main trouble was the fœtid discharge, and it was for that she specially asked advice. The condition had continued for eighteen months. The diagnosis naturally lay between a commencing malignant disease of the body of the uterus and simple catarrh. She had a probe passed from time to time, dressed with pure carbolic, hot douching, and arsenic; and under this treatment she, after three months, was quite cured, and lived for ten years longer.

CASE 2.-A patient, æt. 65, complained of profuse leucorrhoeal discharge, sometimes streaked with blood, and occasionally accompanied by a small clot. She had well-marked backache and occasional griping pains in the pelvis. The uterus was considerably enlarged-about 3 in., hard and globular. In this case the diagnosis was again difficult, but after dilatation of the cervix and curettage of the cavity, with subsequent packing, the patient had no further trouble, and now, after six years, is perfectly well.

I mention the lapse of time, simply because it proves there was no tendency to malignancy in the condition.

CASE 3.-The third and last type of cases is that of a patient who, three years after the menopause, had a sudden and profuse hæmorrhage; it was associated with no pain, the os was gaping and soft, the uterus enlarged to about 3 in. The hemorrhage

continued at intervals of two or three days for three weeks. The woman was extremely emaciated, and appeared in very feeble health. The difficulty here, I confess, was considerable.

With

a view, therefore, to settle the question, I still further dilated the cervix, and finding no specially marked prominence in the walls, I scraped the mucous membrane, applied an escharotic, and afterwards drained by means of iodoform gauze, and the patient had no recurrence of her symptoms after a lapse of five years. This patient had every symptom of cancer, but there being no definite evidence of it on examination, she was treated for the simple condition, and got well.

As I have already said, I could multiply cases to illustrate these types, but I take it that these three illustrate what I consider the three forms of senile uterine catarrh :—

1. Those associated with foetid discharge and no hæmorrhage; 2. Those associated with leucorrhoea and slight hæmorrhage; and

3. Those in which hæmorrhage is the main, if not the only symptom.

Of course everyone is aware that post-climacteric hæmorrhages are due in the main to (1) the commencement of cancer, or (2) to the recrudescence of a fibroid, or (3) occasionally in gouty women, but of course in the gouty condition it is only a form of uterine catarrh, with gouty endometritis as its basis.

The symptoms are extremely like those of malignant disease. The patient suffers from vaginal irritation, and shows marked signs of general cachexia, the skin becoming sallow, and general emaciation sets in. This is really due to a slow sepsis, which is further shown in occasional rigors and night sweats. The most striking symptom, and that for which the patient generally seeks advice, is the vaginal discharge, which is watery and semi-purulent, though frequently it contains a considerable amount of blood. The odour of this discharge cannot be said to be characteristic: it is, as a rule, though not always, most offensive, and in some cases I have seen has been even more so than in marked cases of

cancer. It may cease from time to time, and when it reappears it is generally with a gush of sanious pus. Along with these symptoms there is frequently a certain amount of abdominal pain, pain in the back, and progressive invalidism.'

Per vaginam, one finds the uterus slightly enlarged, or more often normal in size-as a rule, not normally atrophied. The introduction of the sound causes great pain, and if a scraping be removed, this shows inflammatory changes-infiltration of leucocytes, reduplication of cells, and granular degeneration. mucous membrane of the uterus has become hypertrophied and succulent, and is easily detached. In cases of malignant disease of the body of the uterus, all the above-mentioned symptoms are

The

aggravated, but on vaginal examination the uterus is always markedly enlarged and much more fixed than in senile catarrh.

Real 'floodings' are much more common in cancer than in the simple condition. With appropriate remedies, senile uterine catarrh will be found to rapidly improve in the course of a week or two, whereas any treatment other than operative is of no avail in malignant disease; and I have only very seldom found that in doubtful cases the delay at all interfered with the ease with which vaginal hysterectomy was later, if necessary, performed.

Now, with regard to the differential diagnosis between primary corporeal cancer and senile uterine catarrh, the following points. are worthy of consideration :

:

First and foremost, in most cases of primary fundal cancer, periodic and severe pain is an early and prominent symptom; whereas in senile uterine catarrh the pain is irregular and colicky, or if not, it is slight and constant.

Secondly, in cancer, fœtid discharge, at least in the earlier stages, is unusual, because the os is closed, and the surface of the cancer is protected from external influences; whereas in catarrh, especially in the first two forms I have mentioned, foetid discharge is a prominent and early symptom.

Thirdly, local examination in cancer finds the uterus distinctly enlarged, sensitive, and early becomes heavy and fixed; whereas in the simpler condition the uterus either is normal or only slightly enlarged, and remains freely movable throughout.

And, lastly, dilatation and local exploration reveals the presence of a neoplasm in the one case and the absence of all irregularities in the other.

As regards the causes of this senile condition of the uterine mucous membrane, it is difficult to speak with certainty.

1. As a rule, when women have not suffered during their menstrual life from any disorder of the pelvic organs, one may affirm that after the menopause they will be free from uterine disease, since the organs undergo physiological atrophy. But if the patient has been the subject of a fibroid tumour, or has suffered from displacement of the uterus or of any form of inflammation, the uterus may continue large after the menopause, and may be the subject of post-climacteric inflammation, though this is always less marked than when menstrual congestion regularly recurs to aggravate the condition. Yet undoubtedly there are many cases in which senile catarrh occurs, in which there is no history of ante-climacteric disturbance, and in which the uterus is normally poised, and gives no evidence of surrounding inflammation.

2. Tilt pointed out that very often the cervix shrinks, whereas the body of the uterus is inflamed and the fluid becomes pent up, giving rise to colicky uterine pains.

Matthews Duncan had several times to puncture the cervix, so as to allow the escape of inflammatory fluid.

The cases Tilt knew best were those of senile inflammation of the cervix and of the vagina-not so much of the body; and for these post-climacteric inflammations he strongly recommended caustics.

I should like strongly to insist that this condition of senile uterine catarrh is not prodromatic of malignant disease, the two are quite distinct, and I have never seen a case of the simple condition later become one of cancer.

As regards the treatment adopted, when the condition is nonmalignant or doubtful, I have had the best results from rest, hot douching, and the internal administration of arsenic, strophanthus, and Chian turpentine. To give the last-named drug may seem contradictory, as it was long supposed to have beneficial effects in cases of cancer. This I do not believe, but it is quite certain that it has a good effect on inflammatory conditions; and, it seems to me, has almost an equally good effect in clearing up purely uterine inflammation, as in cervical inflammatory hypertrophy.

Nothing gives better results than either the application of escharotics by means of dressed sounds, or, still better, the curettage of the mucous membrane, with subsequent packing and draining.

The main point I wish to insist upon in this paper is the fact that these cases are so often mistaken for malignant conditions; and I have repeatedly had patients, supposed to be suffering from malignant disease, sent to me for hysterectomy, who were sufferers from the simpler condition, and which responded to simple treatment.

Professor Simpson said they were all indebted to the President for calling their attention in his lucid and instructive communication to a subject of much practical importance. He (Prof. Simpson) recognised the faithfulness of the description of senile endometritis, and would only add, in regard to the history of the disease, that it was sometimes associated with senile colpitis. This latter condition sometimes gave rise to much the same train of symptoms, and might occur alone, or as a complication of the intra-uterine mischief. The line of treatment recommended was no doubt the correct one; and in regard to the administration of Chian turpentine, it was easy to believe in its value in the treatment of this simple disease as well as in the treatment of cancer, for which Dr Clay had proposed it as a specific. Like all the turpentines it had a styptic action, which made it serviceable in all the uterine hæmorrhages; and further, it seemed to act as an antiseptic in the blood, and to have a distinct power of lessening the amount and the putrescence of discharges from inflamed and necrotic surfaces.

Dr Barbour thought that this paper was of special value when

M