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.
Fig. 117.—Interstitial endometritis: microscopic section of endometrium removed by the curette (Beyea).
Fig. 118.—Glandular endometritis: microscopic section of endometrium removed by the curette (Beyea).
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.
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.
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.
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.
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.
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.