a normal specimen like Fig. 2. There is comparatively little change in the interglandular connective tissue.

There is marked thickening of the endometrium as a whole; it is much paler and somewhat softened. Catarrh accompanies this form of inflammation, and sloughing of the membrane at menstruation is liable to occur. Ruge has described a "hypertrophic" form in which there is an increase, not in the number of glands, but of the epithelia lining them.'

Karyokinesis has been observed by Cornil in the columnar epithelia. I have described it in other conditions, but have not observed it in this disease, but have no doubt of its occasional presence. (See Fig. 5.)

FIG. 8.-Endometritis interstitialis acuta (membranous dysmenorrhea).

Endometritis Interstitialis Acuta (membranous dysmenor rhea).-There is an unfortunate clashing of terms in the use of "membranous dysmenorrhea." Clinically it is applied to cases of painful menstruation accompanied with sloughing of more or less of the endometrium en masse. This clinical combination is met by more than one form of endometritis. Thus the above form of glandular endometritis would have

1 Ruge, "Schröder's Handbuch," 9. Aufl., S. 174 u. 175.

* Cornil, "Leçons sur les Métrites," Journal des Connaissances médicales, April 21st, 1888

been classed as such. Pathologically the term has been restricted to acute interstitial endometritis superinduced upon a more or less chronic form. Mundé' quotes Virchow as declaring that a deciduous membrane similar to that of pregnancy forms "a statement utterly contrary to present

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knowledge, and not supported by Mundé, who further on states that "the absence of the chorionic villi and of the large, irregular decidual cells of pregnancy [my own italics] easily distinguishes the membrane from the decidua of pregnancy." I have already quoted Wyder's refutation of the

1 Mundé, "Diseases of Women," Mundé and Thomas, p. 628.

granular condition. The reticulum is less proportionately increased. The epithelia of the utricular glands lose in many cases their columnar character, become flattened and widened, or disappear. The calibre of the glands may become crowded with connective-tissue corpuscles. The glands may in places disappear. Sometimes they hypertrophy, taking on, in a slight degree, the alterations of endometritis glandularis.

statement credited to Leopold, that decidual cells were present in this form of inflammation.

The most characteristic change in the endometrium in this form is the great increase in the connective-tissue corpuscles, which become massed thickly together and show a highly

FIG. 10.-Endometritis interstitialis. Complete atrophy of the glands. A, cystic formation; last trace of glands. B, disappearance of glands. (Wyder.)

Endometritis Interstitialis Chronica.-This inflammatory process results in increase of the fibrous connective tissuewhich lies between the glands. In proportion to the degree of this alteration is the tendency to strangulation and atrophy from compression of the utricular glands; hence the terms. "endometritis interstitialis partialis" and "totalis "-names.

FIG. 11.-Endometritis glandularis et interstitialis polyposa. (Wyder.)

which represent simply different degrees of the same process. The process is the formation of a true cicatricial tissue-a sclerosis. The glands, which usually slowly disappear as the sclerosis advances, may here and there dilate and form cysts. These cysts may be lined with cuboidal epithelia.

Endometritis Glandularis et Interstitialis Polyposa.

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This form of endometritis involves glandular and interstitial proliferation and inflammation, with marked tendency to cys tic degeneration. The membrane is much increased in thickness, with great irregularity of surface, is soft and succulent. Vesicles varying from one to eleven millimetres in diameter may be seen upon the surface. They are glands, much distended, lined with cuboidal epithelia, degenerated columnar epithelia. These vesicles or cysts are surrounded by bands of connective tissue. Naturally the cysts are larger as they ap proach the surface. It is claimed by Cornil' that there is a penetration of the glandular tissues into the muscular base beyond the normal depth. The interglandular tissue is much altered. Spindle-shaped, nucleated cells and an increased number of connective-tissue corpuscles, more or less surrounded or embedded in a homogeneous substance, occupy the reticulum.

I omit, as not essential to the aim of this paper, a consideration of the endometrium in adenoma, carcinoma, and sarcoma. The differential diagnosis of decidua can be accomplished without it.

Summary.-1. In extra-uterine pregnancy the endometrium generally changes to decidua.

2. Decidual tissue is pathognomonic of

pregnancy. 3. Portions of the endometrium may be obtained with the curette, examined with the microscope, and decidual tissue recognized if present.

4. Such tissue may be a remnant of an abortion, a part of decidua surrounding a live ovum, or due to an extra-uterine pregnancy.

5. The microscope, in connection with the clinical history, can determine to which variety the species belongs, and, if to the third, confirm the presence of an extra-uterine gestation.

151 EAST 34TH STREET.

1 Cornil, Jour. des Connaissances médicales, April-June, 1888.