EXFOLIATIVE ENDOMETRITIS, OR MEMBRANOUS DYSMENORRHEA. There is a disease which has been called membranous dysmenorrhea or exfoliative endometritis, in which large membranous pieces of the endometrium or a cast of the whole structure is thrown off at the menstrual period (see Fig. 124). The condition is most often found in virgins or sterile women. The membrane may be thrown off at every menstrual period, or at periods separated by intervals of various length. [Illustration: FIG. 124.--Membrane discharged in membranous dysmenorrhea.] The menstrual period is usually accompanied by intense uterine pain, which may resemble labor-pain, and which persists until the separation of the endometrium. In some cases of this disease menstruation is very irregular. The diagnosis is made from examination of the characteristic membrane that is discharged. The condition should not be confused with abortion, in which the large irregular decidual cells will be discovered. Some women are very liable to early menstrual miscarriage, and have repeated accidents of this kind, which in some cases have led the physician to believe that the condition of exfoliative endometritis was present. The local treatment consists of dilatation and curetting of the uterus, which operation it may be necessary to repeat several times. Careful attention should be directed toward re-establishing or maintaining the general health. SENILE ENDOMETRITIS. This disease, also called post-climacteric endometritis, occurs at any period after the menopause. There is a thin seropurulent discharge from the uterus, often so profuse as to soil the clothing. The quantity of the discharge may be increased with a certain monthly periodicity. The discharge is often streaked with blood, or is brown colored from the presence of altered blood. There may be occasional or even continuous slight hemorrhage from the uterus. The discharge is usually fetid, and may be exceedingly irritating to the vagina and vulva. The objective symptoms often resemble in all respects the symptoms of cancer of the body of the uterus. There is usually dull pain in the lower part of the abdomen and the back; and if the disease continues for sufficient time, there may appear symptoms indicative of septic absorption--loss of appetite, emaciation, and slight elevation of temperature. The pathologic changes which take place in the uterus in this disease have not been definitely determined. It seems probable that in some cases the condition may be produced, as in senile vaginitis, by infection of an endometrium the integrity of which had been impaired by the atrophic changes occurring after the menopause. Microscopic examination of portions of the endometrium removed by the curette shows the appearance of long-standing chronic inflammation.