DISEASES OF THE BODY OF THE UTERUS.
ACUTE CORPOREAL ENDOMETRITIS.
Acute inflammation of the mucous membrane of the body of the uterus is
called acute corporeal endometritis. The disease is usually the result
of septic infection occurring at a labor or a miscarriage. Occasionally
acute gonorrheal endometritis is seen, but this disease usually
produces an inflammation of the mucous membrane of the cervix and the
body of the uterus that is chronic or subacute from the beginning.
Septic infection through operative traumatism, through the use of the
uterine sound, or through other gynecological methods of examination
may, of course, result in acute endometritis.
The pathological changes that take place in an endometrium that is the
seat of acute inflammation resemble those seen in acute inflammation
of mucous membranes of other parts of the body. The secretion of the
utricular glands becomes much increased in quantity and altered in
character, becoming purulent and sometimes containing blood.
As would be expected, whenever the inflammation is at all severe the
middle or muscular coat of the uterus is involved by the process; in
other words, a _metritis_ follows and accompanies the endometritis. In
puerperal metritis abscesses varying in size from a pin-head to that of
a hen’s egg are sometimes found in the uterine wall.
The septic infection may extend through the muscular wall of the
uterus and involve the peritoneal covering, producing in this way a
_perimetritis_.
Acute inflammation of the endometrium sometimes occurs during the
course of the exanthemata. The changes that take place in the mucous
membrane of the uterus are similar to those seen in other mucous
membranes during the course of these diseases. The local condition is
usually limited by the duration of the general disease.
It is probable that some of the cases of arrested development of the
internal organs of generation, and cases of chronic tubal and ovarian
disease seen in later life, may be traced to this exanthematous form of
endometritis occurring during girlhood.
The symptoms of acute endometritis vary very much in severity. Dull
pain in the region of the uterus, referred to the supra-pubic region
and the sacrum, is usually present. Reflex disturbance of the bladder,
characterized by frequent and often painful urination, may be present;
and it is very probable that mild cases of endometritis have been
diagnosed and treated as light attacks of cystitis. The temperature in
the puerperal cases may be very high. The discharge from the cervix
is very much increased, is puriform in character, and is occasionally
streaked with blood.
Digital examination shows that the external os is patulous, the cervix
enlarged and soft, and the body of the uterus somewhat enlarged and
tender upon pressure. This tenderness may be elicited by pressing
the fundus between the vaginal finger in the anterior vaginal fornix
and the abdominal hand. Examination through the speculum shows
the discharge escaping from the external os. In case the cervical
mucous membrane is also involved, a red area of erosion will be seen
surrounding the os.
Acute endometritis of non-puerperal origin is best treated by rest in
bed, vaginal douches of hot boric-acid solution (ʒj to a pint of water)
or of bichloride of mercury (1:4000) at a temperature of 100° to 110°,
and the continuous use of saline purgatives. Active intra-uterine
treatment in these cases is not necessary. When, however, the disease
occurs, as it usually does, from septic infection at a miscarriage or a
labor, more radical treatment must be used. This treatment comprises
frequently-repeated intra-uterine douches, thorough curetting of the
uterus, and, finally, hysterectomy in extreme cases.
Every case of acute endometritis should be carefully watched and
treated until the disease is cured. Acute endometritis, especially if
gonorrhea is the cause, is very prone to become chronic and to extend
to the mucous membrane of the Fallopian tubes and the ovaries.
CHRONIC CORPOREAL ENDOMETRITIS.
Chronic inflammation of the endometrium, or chronic endometritis, is
much more frequently seen in practice than the acute form. It may
occur as a primary disease, but it very often occurs as the result of
some other pathological condition of the uterus, as, for instance,
subinvolution or uterine fibroid.
A variety of confusing terms have been used to designate the different
forms of endometritis. There seem to be two chief forms of the
disease: I. Chronic interstitial endometritis; II. Chronic glandular
endometritis.
In the first form of the disease the interglandular tissue is
chiefly involved. The spaces between the glands are infiltrated with
connective-tissue cells.
In the second or glandular form of endometritis the disease affects
the glandular apparatus. The utricular glands become much elongated,
branched, and increased in number. The accompanying illustrations
(Figs. 117, 118) show the microscopic appearance of interstitial
endometritis and glandular endometritis.
These two forms of endometritis are often mixed, and the same uterus
may present the glandular form of inflammation upon part of the
endometrium, the interstitial form upon another part, and the mixed
form upon still another part.
The gross appearance of the endometrium varies with the form of the
disease and its duration. It will be remembered that in the mature
uterus, in the menstrual interval, the mucous membrane is a thin
reddish-gray structure about 1 millimeter (1/25 inch) in thickness.
In the different forms of endometritis the mucous membrane may become
hypertrophied to three or four times this thickness. In some unusual
cases the mucous membrane may become even still further hypertrophied,
attaining a thickness of half an inch. A special name, _fungous
endometritis_, has been given to the disease when it assumes this form.
Microscopic examination shows that fungous endometritis is merely a
mixed form of the glandular and the interstitial varieties, with a
great increase of all the elements of the mucous membrane. In fungous
endometritis the hypertrophy of the mucous membrane may be uniform
throughout the body of the uterus or it may occur only in localized
areas.
[Illustration: FIG. 117.--Interstitial endometritis: microscopic
section of endometrium removed by the curette (Beyea).]
[Illustration: FIG. 118.--Glandular endometritis: microscopic section
of endometrium removed by the curette (Beyea).]
[Illustration: FIG. 119.--Polypoid endometritis (Beyea).]
In some cases the glandular hypertrophy of the mucous membrane assumes
the form of polypoid growths projecting into the uterine cavity (Fig.
119).
In the advanced stages of all the forms of endometritis cicatricial
formation takes place. The normal ciliated epithelium of the
endometrium is cast off, and is replaced by flat squamous cells. The
glands atrophy; the glandular openings become dilated, and ultimately
appear as simple depressions on the surface. In time secretion from the
glands ceases, and the cavity of the uterus becomes lined with simple
connective tissue.
Chronic endometritis is always accompanied to a greater or less extent
by inflammation of the muscular coat of the uterus. The pathological
changes that take place resemble those occurring in chronic
inflammation in similar musculo-fibrous structures in other parts of
the body. A section of the uterine wall is much lighter in appearance
than normal, and the whitish bundles of connective tissue are seen
interlacing with the more vascular muscular fibers.
At first there is an hypertrophy of the uterine wall from infiltration
of inflammatory material. In the latest stages organized connective
tissue is formed, and there is produced a sclerotic condition of the
uterus, with atrophy of its normal muscular elements.
The hypertrophy of the uterus, however, that accompanies most of
the forms of endometritis is not due altogether to the presence of
inflammatory deposits. The uterus possesses the peculiar property of
enlarging, by a general hypertrophy of its elements, whenever there is
present in its cavity any gross pathological condition. We see this in
fibroid tumor. And, as a general rule, the enlargement is proportional
to the mensurable size of the disease.
The metritis may involve the whole of the uterine body, or it may
occur in localized areas. It may affect only the body of the uterus,
or the body and the cervix, or, as we have already seen, the cervix
alone. When the disease is localized to part of the uterine wall,
the induration of the affected area may sometimes be determined by
palpation.
=Symptoms.=--The symptoms of chronic endometritis are often obscured
by symptoms that are to be referred to other accompanying conditions.
For instance, the endometritis very often accompanies subinvolution of
the uterus, laceration of the cervix, uterine displacement, or ovarian
and tubal disease. Cases of simple uncomplicated endometritis are the
exception.
The menstrual function is usually affected. The period is of longer
duration, the loss of blood is greater, and the periods may occur more
frequently than normal; in other words, there is present menorrhagia.
In this disease bleeding also occasionally occurs between the menstrual
periods. Hemorrhage is a symptom that is most prominent in cases of
interstitial and fungoid endometritis.
The secretion of the utricular glands is also increased in amount. This
symptom is most pronounced in cases of glandular endometritis. The
secretion is thin and purulent in character, and is often streaked with
blood. It decomposes very readily, and consequently is often offensive
and excites the suspicion of malignant disease.
The character of the typical discharge from the body of the uterus is
usually obscured by admixture with discharge from the cervical mucous
membrane. Cervical catarrh, or inflammation of the cervical mucous
membrane, may, and usually does, occur alone, without involvement
of the upper endometrium, but chronic corporeal endometritis is
usually associated with inflammation of the cervix. If the discharge
is observed at the vulva, it will be still further altered by
admixture with the vaginal secretion. The discharge from the corporeal
endometrium is thinner and more serous than the mucus of the cervical
canal, and is more usually purulent and streaked with blood.
The discharge from the endometrium is very often increased very
decidedly immediately before and after the menstrual period.
Pain is a general symptom of chronic endometritis. The pain is uterine
in character, and is referred to the lower abdomen and the back. There
is also very constantly present reflex headache localized on the top of
the head or in the occiput.
The pain may be present at all times, but it is usually most marked
when the woman is upon her feet and the pelvic congestion is increased.
The pain is always greatest immediately before and during the menstrual
period.
General physical weakness and debility are often very pronounced, and
seem to be out of proportion to the extent of the local disease. This
same phenomenon has been spoken of in the consideration of uterine
displacements. The weak and aching back, the dragging sensations in the
pelvis, the tired legs, may all appear after the woman has been upon
her feet but a short time, and utterly incapacitate her for any kind of
labor.
Nervousness, neurasthenia, hysteria, and mental depression and
melancholia are apt to occur in this disease. Such nervous phenomena
are common to all diseases of the uterus. The mental depression is
often very marked, and is exaggerated before and during each menstrual
period.
The woman with chronic endometritis is usually sterile; or if she
becomes pregnant, abortion will probably occur. The discharges in
the uterine cavity are inimical to the spermatozoa, and the diseased
endometrium furnishes an inefficient place for the attachment of the
ovum.
Physical examination in a simple case of chronic endometritis shows
a somewhat enlarged uterus, more globular in shape than normal. The
fundus uteri is tender on pressure between the vaginal finger and the
abdominal hand. The external os is usually patulous.
Examination with the speculum shows the discharge escaping from the
external os. If there is also present cervical endometritis, the
discharge presents the characteristics of both cervical and corporeal
mucus. It is thick and tenacious, puriform, and often streaked with
blood. After the cervical canal has been wiped out the characteristic
corporeal discharge may appear unmixed with cervical mucus. This
discharge is thin, purulent, and may be streaked with blood, or it may
be brownish in color from mixture with altered blood.
If the uterus is examined with the uterine sound, it will be found that
the internal os is patulous; the fundus is decidedly tender upon gentle
pressure with the sound, and even the gentlest use of the sound may be
followed by bleeding.
The patulous condition of the cervical canal and the internal os is a
constant characteristic of all kinds of gross disease in the cavity
of the uterus. The external os is usually patulous when the cervical
mucous membrane is diseased. The external os, the cervical canal, and
the internal os are open when the corporeal endometrium is diseased.
The only certain method of making the diagnosis is by the use of the
sharp uterine curette, and this instrument should always be employed
whenever there is even the slightest suspicion of the possibility of
malignant disease of the endometrium. The cervical canal is usually
sufficiently open to permit the use of the curette without dilatation
and without an anesthetic. Three or four strips of the endometrium
should be removed from different parts of the uterine cavity, and
should be submitted to microscopic examination. It is always safest
to perform curetting for diagnosis at the house of the patient, and
to keep her in bed for two or three days after the operation. Strict
antisepsis should be observed.
The causes of chronic corporeal endometritis are various. Almost any
disease of the body of the uterus or of the cervix may eventually
result in this condition; therefore the different causes of chronic
endometritis will be better appreciated after a discussion of diseases
of the uterus. Laceration of the cervix, subinvolution, flexions and
versions, fibroid tumors, etc., all produce, in time, some form of
chronic endometritis.
Primary chronic endometritis may result as a later stage of the acute
disease, or it may exist from the beginning in the chronic form. This
is especially true of endometritis caused by gonorrhea. Here the
invasion of the disease is slow and insidious, and in the majority of
cases is preceded by no determinable acute stage.
Sometimes endometritis appears in old women. Bleeding from the uterus,
purulent discharge, and pain may be present. The condition is due to
the atrophic changes of senility occurring in the endometrium--changes
that resemble those that take place in the mucous membrane of the
vagina and the external genitals. Though such symptoms may be
indicative merely of a benign condition, yet, as they are also
characteristic of the early stages of malignant disease, they demand
immediate thorough examination and careful watching.
=Treatment.=--As chronic endometritis is usually secondary to some
disease of the cervix or body of the uterus, the treatment should be
directed toward the cure of this primary condition.
The operation of trachelorrhaphy will cure the subinvolution of
the uterus and the resulting endometritis. Forcible dilatation of
the cervix, in the case of an old anteflexion, will relieve the
inflammation of the endometrium. Correction of a retroversion will
likewise relieve the resulting endometritis. Therefore, though in every
case the cure may be hastened by treatment applied directly to the
endometrium, yet causative or complicating conditions must always also
be treated if we wish the cure to be lasting.
Many cases of mild endometritis may be relieved or cured by attention
to the general hygiene and habits of the woman and by applications
made only to the vaginal aspect of the uterus. The dresses should
be worn loose about the waist and supported from the shoulders.
Prolonged standing and slow walking should be avoided. Mild purgation
with salines should be maintained. Regulated exercise or general
massage should be prescribed. In addition, the vaginal douche, iodine
applications, and the use of the glycerin tampon, with depletion from
puncture of the cervix, should be used, as has already been prescribed
for the subinvolution accompanying laceration of the cervix.
If these methods fail after careful trial, direct treatment must be
applied to the endometrium.
The present method of treating chronic corporeal endometritis directly
is by the uterine curette. Time is wasted by the use of applications to
the interior of the uterus, and a great deal of harm has resulted from
such applications carelessly made.
The best curette is the Sims sharp curette (Fig. 120). The Martin
curette (Fig. 121) is useful to remove the endometrium from the fundus.
The operation had best be performed in the menstrual interval, though
it may safely be performed during the menstrual period. An anesthetic
should always be administered. The woman should be placed in the
dorso-sacral position, with the feet in the supports. The vulva,
vagina, vaginal cervix, and buttocks should be thoroughly sterilized.
[Illustration: FIG. 120.--Sims’s sharp curette.]
The anterior lip of the cervix should be grasped with a double
tenaculum. The cervical canal should be wiped out with a small sponge
or with cotton and irrigated with bichloride, if the external os is
sufficiently patulous. The cervical canal and the internal os should
then be dilated to about one inch. The position of the uterus should
have been previously determined by careful bimanual palpation.
[Illustration: FIG. 121.--Martin’s curette.]
The Sims curette should be gently introduced to one cornu and then
drawn methodically over the whole of the uterine surface, removing the
endometrium in parallel strips, the length of each strip being equal to
the distance between the internal os and the fundus. The curette may be
withdrawn from the uterus and washed in distilled water as each strip
is removed, or withdrawal and washing may be done after two or three
strips have been removed. The Martin curette should then be introduced
to one cornu and scraped over the fundus, as there is usually in this
situation a narrow strip of endometrium that is not removed by the Sims
curette.
The uterus should then be washed out with warm sterile water or with
a 1:4000 bichloride solution. The washing may be done by holding the
cervical canal open with the small dilator and introducing the long
tubular syringe nozzle, or by some form of reflux tube (Fig. 122).
Opportunity must always be afforded for the escape of the irrigating
fluid.
[Illustration: FIG. 122.--Irrigation of the uterus.]
The operator should always remember the danger of perforating the
uterus by the curette. This accident, which has happened in the hands
of the best surgeons, occurs usually as the instrument is introduced,
not as it is withdrawn. It is much more liable to occur after labor
or recent abortion, when the uterine tissues are soft, than in the
conditions now under consideration. If perforation should happen, the
uterus should be carefully washed out with the bichloride solution, the
vagina should be lightly packed with gauze, and the patient returned
to bed. A hypodermic injection of ergotin should be administered, and
afterward, when the woman recovers from the anesthetic, small repeated
doses of fluid extract of ergot should be administered to ensure
uterine contraction. If the operation has been performed aseptically,
it is probable that no harm will result from the accident. If
peritonitis should develop, celiotomy must immediately be performed.
After curetting the uterus some operators are in the habit of packing
the uterine cavity with sterile or iodoform gauze. This procedure is
liable to obstruct the escape, rather than favor the drainage, of any
discharges from the cavity of the uterus. Elevation of temperature and
uterine pain are often caused by it; therefore it is best, after the
operation of curetting, merely to pack the vagina lightly with sterile
gauze, which should be removed in forty-eight hours. Daily douches of a
1:4000 bichloride-of-mercury solution should then be administered as
long as the woman remains in bed. The vagina should be carefully dried
after the douche, as already advised.
Hemorrhage is never profuse during curetting, and usually ceases after
the endometrium has been removed and the uterus has been washed out.
In cases of gonorrheal endometritis it is advisable, after the uterus
has been douched and the bleeding has ceased, to apply carbolic acid
thoroughly over the whole interior of the uterus, because infection may
lurk in the distal ends of the utricular glands, which are not removed
by the curette.
[Illustration: FIG. 123.--Microscopic section of the normal
endometrium, showing the utricular glands extending into the muscular
tissue (Beyea).]
The length of time during which it is advisable to keep the woman in
bed depends upon the extent and nature of the disease for which the
curetting has been done. As a general rule, the longer the stay in
bed the better it is for the woman. If the uterus is much enlarged or
if subinvolution is present, the patient should stay in bed for two
weeks. Such rest in the recumbent position diminishes the congestion
of the pelvic organs and is of great aid in restoring the parts to a
normal condition. Careful attention should be paid to the regularity of
the bowels. Mild purgation with saline purgatives should be continued
during the convalescence. Daily massage, started two or three days
after the operation, will facilitate the cure.
All the endometritial structures are never completely removed by the
curette. The distal ends of the utricular glands, which penetrate the
muscular coat of the uterus (see Fig. 123), remain after thorough and
vigorous curetting.
After removing the endometrium with the curette the cavity of the
uterus does not become lined with a cicatricial membrane, but a new
endometrium is produced. It is probable that the new membrane is
developed from the remains of the utricular glands. The new endometrium
grows in a very short time. In some cases it has been sufficiently well
formed to permit pregnancy five weeks after curetting.
The first menstrual period, and sometimes the second and third, after
the operation of curetting may be missed. As a general rule, the
menstrual bleeding is much less profuse than before the operation.
The therapeutic object of curetting for endometritis is to replace the
diseased endometrium by a new membrane which has grown under conditions
of rest and asepsis.
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.
These cases are often mistaken for cancer of the body of the uterus,
and the diagnosis should always be immediately made by microscopic
examination of the material removed by a thorough curetting of the
whole of the uterine cavity.
The treatment of senile endometritis consists of applications to
the endometrium of a solution of nitrate of silver, from one-half
to one dram to the ounce of water, or of thorough curetting of the
endometrium.