PART II SPECIAL DIAGNOSIS (Part 1)

PART II SPECIAL DIAGNOSIS CHAPTER XI THE DIAGNOSIS OF ENDOMETRITIS, INCLUDING GONORRHEA AND EROSIONS OF THE CERVIX UTERI Anatomy and physiology of the endometrium, p. 166. Pathology, p. 169. Anatomico-pathological classification, p. 170. Endometritis from a clinical point of view, p. 173: Acute non-gonorrheal endometritis, p. 173; Etiology, p. 173; Symptoms, p. 174; Signs, p. 176. Chronic non-gonorrheal endometritis, p. 176; Varieties, p. 176, (1) Of puerperal origin, or post-abortum, p. 176, (2) Those varieties which are not preceded by a known acute stage, p. 177; Etiology, p. 177; Symptoms, p. 177; Signs, p. 178. Gonorrheal endometritis and gonococcus infection, p. 179. Acute gonorrheal endometritis, acute gonorrheal endocervicitis, p. 180; Symptoms, p. 181, Diagnosis, p. 181, Differential diagnosis, p. 181; Chronic gonorrheal endometritis, p. 182: Latent gonorrhea in women, p. 182; Differential diagnosis of chronic gonorrheal endometritis, p. 183. Senile endometritis, p. 183. Endocervicitis, p. 184. Erosions of the cervix uteri, p. 184: Characteristics, p. 184; Diagnosis, p. 185; Differential diagnosis, p. 186. Although endometritis is a part of the inflammatory process called Pelvic Inflammation, it may exist without involvement of the periuterine structures. As pelvic inflammation is most often caused by infection introduced through the vagina and uterus, so endometritis is generally a beginning stage of pelvic inflammation. The term endometritis will be used to define inflammation of the endometrium. Endocervicitis is the name given to the inflammatory process when it is limited to the cervix. The differentiation of endocer- vicitis from endometritis of the body has a practical importance in the acute infections, especially in gonococcus infection, and also in the chronic form of inflammation where the disease is apt to be situated chiefly in the cervical canal. An inflammatory process situated in the endometrium may extend to the muscular structure of the uterus, and then the process may be defined more exactly as a metritis. In practice the diagnosis of metritis aside from endometritis 165 166 THE DIAGNOSIS OF ENDOMETRITIS is an academic affair and of no practical significance even when it is possible to diagnose one without the other; therefore, little will be said of metritis, with the understanding that in the severe grades of endometritis there is present also metritis. ANATOMY AND PHYSIOLOGY OF THE ENDOMETRIUM A word as to the anatomy and physiology of the endometrium before taking up the consideration of the different manifestations of inflammation. The following description applies to the un- impregnated uterus of the healthy adult woman between menstrual periods. It will be noted that the mucosa of the cervical canal is anatomically and physiologically different from the mucosa of ___ the uterine cavity proper, therefore y<^ """"^V we are justified in considering the /'.V. ^y\ word endometrium as applying to / ^-- .iz^< v foe latter only. \i;- ""■— —^ .-_.,. • -y The interior of the uterus is ^m. , / x-yv divided into two cavities: the cavity ^^xr===^!zr^^ / of the body, and the cavity of the In !7 neck, which are separated from each \ ■ other by the constricting ring of V;; {mmi^ >7' muscular tissue about the internal N^jU==tr^ t os- ^ne shape of these cavities has J^\ ;***«»; ^7 been referred to elsewhere, the cav- \ ^ / / ity °^ ^ne b°dy being represented by 1j| ij y an inverted isosceles triangle with Fig. 64. — Reconstruction of the two angles of the base in the Uterus, Showing Shape of Uterine uterine cornua and the third angle Cavity and Cervical Canal. (Wil- ^ ^ 'mim^\ 0S. The anterior hams.) and posterior walls of the uterus meet at the sides at an acute angle so that there are no lateral walls proper, therefore the uterine cavity is flattened from before backward. The cervical cavity is fusiform in shape, largest in the middle and contracted at the internal and external ora. Under resting conditions the cavity of the body is closed against infection from below at the internal os and from infection from above by the muscular constrictions at the isthmuses of the Fallopian tubes. The cavity of the cervix in like manner is protected from ANATOMY AND PHYSIOLOGY 167 infection from above by the narrowing at the internal os, and from below in the nulliparous uterus more, and in the parous uterus less, by the constriction at the external os. The wall of the uterus is made up of three layers, the thin, serous, peritoneal layer, the thick muscular layer — composing most of the structure of the uterus — and the medium thick mucous layer. The mucous layer, the endometrium, consists of the utricular glands, connective tissue, blood-vessels, nerves, and lymphatics. It is covered by a single layer of ciliated columnar epithelium — which also lines the glands — and is continued through the Fallopian tubes. &i ■~X:.::.;-:iSZ^J£. : <"''M Fig. 65. — Normal Endometrium. (Williams.) The endometrium is essentially a glandular structure. The glands are tubular and branching, several opening often by one mouth. They extend into the muscular layer and all open into the4 uterine cavity. In the body of the uterus the endometrium is closely united to the muscularis, whereas in the neck it is freer. In the cervix uteri the lining epithelium shades into pavement epithelium at the external os. In this cavity the mucous mem- brane is thrown into oblique ridges which diverge from an anterior and posterior longitudinal raphe, presenting an appearance which has received the name of arbor vitae. 168 THE DIAGNOSIS OF ENDOMETRITIS The normal secretion of the uterine glands is a clear, watery fluid, having an alkaline reaction, that of the glands of the neck is clear and viscid; it is also alkaline. Throughout the cervical mucosa are found a variable number of little cysts, presumably glands, which have become occluded and distended with retained secretion. They are called the ovula Nabothi, or Nabothian follicles. The endometrium shows normally many differences in structure from infancy to old age and during the intermenstrual and menstrual cycles. Before puberty it is relatively thin and undeveloped, nearly all of it having the character of the cervical mucosa. Our views as regards the normal histology of the endometrium have of recent years undergone a considerable change, due to the important observations of Hitschmann and Adler (Monatssclnift fur Geburts. und Gynaekol.j 1908, XXVII. , 1), confirmed by several subsequent investigators. Hitschmann and Adler, after a painstak- ing study of the uterine mucosa from fifty- eight women at various periods of the t- nn Tr • i ^ x menstrual cycle, found that the endome- Fig. 66. — Virginal Exter- J ' nal Os. (Williams.) trium from the cessation of one menstrual flow to that of the next, presents a con- stantly changing histological picture. This cycle of changes they divide into four phases; postmenstrual, interval, premenstrual, and menstrual. At the height of the menstrual flow the mucous membrane diminishes in thickness and the glands pour out their secretion, becoming narrow and straight. The surface epithelium is frequently lost, but this is not an invariable rule. After the period there takes place a very rapid cell growth in both the epithelium and connective tissue. The glands become larger and wider, although still quite narrow and straight. The epithelium is low and in a condition of rest. By about the fifteenth da)^ the cell growth of the epithelium has progressed to such an extent that the glands become somewhat tortuous, and often assume a spiral or corkscrew-like appearance. Finally, six or seven days before the beginning of menstruation, the glands rapidly enlarge and become tortuous, the cells bulge into the lumen, the epithelium PATHOLOGY 169 becomes higher and broader, and the lumen is filled with a mucous secretion. These gland changes are much more marked in the deeper portion of the mucosa than in the superficial, so that there is produced a well-marked differentiation into a superficial compact and a deep spongy layer. In this respect there is a marked similarity to the appearance of the young decidua, the resemblance being increased by the fact that the interglanclular stromal cells in many cases assume an appearance very similar to or approaching that of decidual cells Fig. 66a. — Parous Exter- During pregnancy the mucosa of the cor- nal 0s. (Williams.) pus uteri is enormously congested. Its fimction is the formation of the decidua — the connective-tissue cells of the endometrium going to make the decidual cells of pregnancy. Following the menopause there is an atrophy of the endometrium coincident with the shrinking of the uterus so that in the old woman the uterine glands are found almost entirely obliterated, and there is apt to be partial or complete closure of the uterine canal at the internal os. PATHOLOGY It is probable that all forms of endometritis are due to bacterial' invasion of the endometrium. The endometrium under normal conditions is sterile, and bacteria in small numbers introduced from without are promptly destroyed. Although chemical irrita- tion and trauma may cause congestion and favor bacterial growth, the idea that these influences and " constitutional taints" do any- thing more than provide a fertile soil for the microorganisms has gone the way of many older theories. The following bacteria have been found in the endometrium in cases of endometritis — seldom in pure cultures, generally in mixed infections: — Staphylococcus pyogenes albus, citreus, and aureus. Streptococcus pyogenes. Gonococcus. 170 THE DIAGNOSIS OF ENDOMETRITIS Colon bacillus. Tubercle bacillus. Diphtheria bacillus. Typhoid baccillus. Pneumococcus. Bacillus aerogenes capsulatus. Spirochaeta pallida of syphilis. In many forms of endometritis the bacterium reaches the endo- metrium from without by way of the vagina ; in a smaller number of varieties it comes from the Fallopian tubes or abdominal cavity through the lumen of the tubes; and in still other varieties it comes through the lymphatics and veins of the uterine wall from near-by sources of infection in peritoneum, rectum, or bladder; and rarely it reaches the endometrium from distant sources through the blood current. The classification of endometritis has long been a stumbling block to the gynecologist. A recent writer on the subject gives a pathological classification containing eleven different forms, accord- ing to the macroscopic or microscopic appearances of the different varieties, and a clinical classification of ten different sorts of chronic endometritis. A bacteriological classification will ultimately be the one chosen as a guide to diagnosis. At present, not enough facts are known to justify its use. As it is impossible to diagnose the different varieties according to the pathology, except by examination of scrapings from the endometrium, and, according to the present state of our knowledge of the pathology of the endometrium, the differ- entiation of the varieties has no bearing on the treatment, we shall consider the subject from the clinical point of view. Suffice to mention the forms of endometritis which have been recognized as a result of the microscopic examination of scrapings and of uteri removed by operation. ANATOMICO-PATHOLOGICAL CLASSIFICATION Hypertrophic endometritis, in which the endometrium is thickened and soft. If the glands are increased in size only, it is called hypertrophic glandular endometritis, if they are increased in number it is called hyperplastic glandular endometritis. ANATOMICO-PATHOLOGICAL CLASSIFICATION 171 F. Hitschmann and L. Adler (Zeit. f. Gebs. u. Gun., 1907, LX., 63) state that endometritis glandularis hypertrophica and endo- metritis glandularis hyperplastica have nothing whatsoever to do with inflammation. The first is not even a pathological condition of the uterine mucosa but corresponds to the premenstrual .state of the normal lining of the uterus; the latter consists partly of the normal premenstrual condition, and partly of variations in the number of glands within physiological limits; in addition it includes cases in which there is a glandular hypertrophy of the uterine mucous membrane, but this also is a change which is entirely independent of inflammation. There is, according to these investigators, but one variety of inflammation of the uterine mucosa, endometritis interstitialis, or, as it is usually called, en- dometritis. The diagnosis is made by demonstrating the cells of infiltration, so- called plasma cells. If the inflammatory proc- ess affects chiefly the inter- glandular connective tissue the process is known as in- terstitial endometritis. This form has an acute and a chronic stage, the acute being characterized by dif- fuse or circumscribed infil- tration of the stroma by small round cells with congestion of the blood-vessels and a serous exudate in the spaces of the connective tissue1 (exudative interstitial endometritis). The chronic stage is characterized by newly formed connective tissue resulting in com- pression of the utricular glands, and, in the later stages in atrophy of the endometrium, the so-called atrophic endometritis. Retention cysts may be formed in the interglandular spaces of the connective tissue and cystic interstitial endometritis results, or the glands may be obstructed by the pressure of the connective tissue at their mouths, cystic glandtdar endometritis. Fungous endome- tritis is the term applied when the mucosa is tin-own into folds; villous endometritis, when it is covered with shaggy villosities; and Fig. 67. — Horizontal Section of the Up- per Part of the Body of the Uterus. 172 THE DIAGNOSIS OF ENDOMETRITIS polypoid endometritis, when one or more mucous polyps are present. When a layer of necrotic tissue, composed of degenerated epithelium, blood, leucocytes, microorganisms, and fibrin is found on the surface of the endometrium — as in certain infections follow- ing labor and abortion— the condition is known as pseudodiph- theritic endometritis, and when true ulcers form in the endome- F'ig. 68. — Transverse Longitudinal Section of the Uterus. trium — as in carcinoma and tuberculosis— the process is called ulcerative endometritis. Decidual endometritis is the name given to inflammation of the endometrium during pregnancy. It is diagnosed definitely by microscopic examination of the deciclua after expulsion of the fetus. Evidences of inflammatory action are present. The symptoms may be hydrorrhea uteri gravidi, or pains in the uterine region during pregnancy. A rare condition is exfoliative endometritis, so-called membranous dysmenorrhea. It consists of the discharge from the uterus of a ACUTE NON-GONORRHEAL ENDOMETRITIS 173 more or less incomplete cast of the cavity of the corpus uteri, in the shape of a sac, triangular in form, gray in color, and of a rough surface. Floated in water and laid open, its interior is smooth. When examined under a- magnifying glass it is seen to be studded with minute openings which represent the mouths of the utricular glands. When the sac is reasonably complete the openings of the Fallopian tubes may be distinguished at the upper angles of the sac. The membrane is from one to three millimeters thick and under the microscope shows much the appearances of exudative interstitial endometritis, although the pathological appearances vary in different cases. Tuberculous endometritis, relatively rare, is a sequel often of primary tuberculosis of the tubes. Rarely it is primary in the cervix. Tuberculous infection may reach the endometrium also from without by coitus, or by instrumental or digital interference. Occurring in the late stages of general tuberculous infection of the genito-urinary system, it has no clinical importance, because the other manifestations of the disease are of overshadowing seriousness. It is characterized by the presence of giant cells, tubercles, and tubercle bacilli found microscopically in scrapings made from the endometrium. The tubercle bacilli may be detected in the uterine discharges. Many cover-slip preparations should be studied before affirming the absence of the bacillus. Not much is known of the forms of endometritis occurring after the acute infectious diseases — typhoid fever, diphtheria, scarlet fever, measles, and smallpox — nor of the endometritis which attends syphilis. Gonorrheal endometritis will be considered separately under the clinical classification. ENDOMETRITIS FROM A CLINICAL POINT OF VIEW The subject is best divided into acute and chronic endometritis, with special consideration of gonorrheal endometritis, senile endome- tritis, and endocervicitis. Acute Non-goxorrheal Endometritis Etiology.— This is an inflammation due to invasion of the endometrium by septic microorganisms, more especially the staphylococcus and the streptococcus. It is a grave form of en- 174 THE DIAGNOSIS OF ENDOMETRITIS dometritis as contrasted with a majority of the chronic forms of en- dometritis, which are of a mild type and have no recognizable acute stage. Its chief causes are: (1) infection following labor and abortion; (2) the use of uncleanly fingers or instruments in making office treatments; (3) operations which are not aseptic, and (4) sloughing intra-uterine tumors. (1) Infection following labor and abortion is the most frequent cause of acute endometritis. It can not be entirely avoided even with the most scrupulous care. Retained membranes may de- compose and cause it. Too often the physician is to blame. Bacteria brought to the vagina on carelessly washed hands, lack of thoroughness in the preparations for the immediate repair of the injuries of the pelvic floor and perineum following labor, the unnecessary use of forceps, or too frequent vaginal examinations, to say nothing of too much douching — thereby washing away the normal secretions of the vagina, which, according to Doder- lein destroy pathogenic bacteria — all play an important part. The great danger of so-called septic endometritis, which attends criminal abortion, is too well known to require extended comment. (2) The general practitioner of medicine, realizing the necessity of washing his hands after an examination, is careless about washing them before making a vaginal examination or instrumental treat- ment. The practice of making intra-uterine office treatments is dangerous even with strict asepsis, besides being useless as a therapeutic measure. Passing the sound into the uterine cavity should be clone only under strict aseptic precautions and with the. utmost gentleness to avoid trauma. (3) Minor operations may cause as great harm as major ones and too commonly do so because the preparations for the lesser pro- cedures are not as carefully made. (4) Sloughing of a uterine polyp, of a pedunculated submucous fibroid, or of an inverted uterus sometimes results in septic endo- metritis unless prompt operative measures are instituted. Symptoms. — The symptoms of acute endometritis with septic absorption, acute septic endometritis, manifest themselves within twenty-foil