PART II SPECIAL DIAGNOSIS (Part 2)

to forty-eight hours after infection, although they may be delayed for several days. Their severity depends upon the form of infection. A septic intoxication which is due to the absorption ACUTE NON-GONORRHEAL ENDOMETRITIS- 175 into the system of ptomaines. — the product of decomposition set up by bacteria, — is called sapremia; that which is due to the absorption of the bacteria themselves with their toxins is known as septicemia proper. As yet we have no means of determining which form of infection is present in any given case. We know that the form caused by the streptococcus is the more grave, that the streptococcus may be diffused very rapidly throughout the system, and that in death resulting from this form there may be found few pathological changes in the pelvic organs. The staphylococcus, on the other hand, is more apt to produce marked local reaction and pus formation. The severity of the symptoms will vary according to the continued presence of the source of infection and the rapidity of its absorption. Although the endometrium is the point of en- trance of the infective material into the system and endometritis is the first manifestation of the poisoning, the disease is a general one almost from the first. In the later stages of the disease the involvement of tissues neighboring to the endometrium — the uterine muscle, pelvic cellular tissue, the Fallopian tubes, and peritoneum — produces complications which overshadow the endometritis. The symptoms are ushered in by a severe chill, followed by elevation of temperature (103°-104° F. or higher), and a rapid pulse (110- 120 or higher). If the disease follows labor or abortion the lochial discharge is diminished in amount at first and then increased, be- comes dark in color, then purulent, and generally, though not in the streptococcic form, has an offensive odor. If the disease does not follow labor or abortion a bloody, purulent, usually offensive uterine discharge is a constant symptom after the initial chill. Intermittent uterine pains— becoming continuous and severe if the inflammatory process reaches the peritoneum — nausea, constipation, and frequent and painful micturition are early symptoms. Irregularly recurring chills, high temperature, rapid and feeble pulse, a sense of well-being and apathy, the characteristic un- described odor of sepsis, diarrhea, and failing strength, are symptoms of the advanced stages of the disease. Acute endometritis without sapremia or septicemia, is attended by comparatively slight constitutional disturbances and the symptoms are limited to elevation of temperature— generally preceded by a chill — pain of moderate severity in the lower abdomen, frequeni and painful micturition, nausea, and disturbance of menstruation 176 THE DIAGNOSIS OF ENDOMETRITIS either suppression or menorrhagia. The symptoms abate in a few days. Signs. — In all forms we find on physical examination, — the uterus enlarged and soft, tender to light pressure in all parts; the vagina hot and dry; the uterine discharge wanting at first and later increased in amount. The os is patulous. Rigidity and tenderness of the abdominal muscles, called peritonismus, is to be expected if the peritoneum is involved in the inflammatory process, other- wise not. Acute endometritis without complications is uncommon. If the case is seen early an anesthetic should be given because of the great pain caused by manipulation. Thorough aseptic precau- tions are observed. A soimd is passed into the uterus and retained membranes, or sloughing tumors, polypi, or fungosities are detected by sound-touch. In cases of doubt the cervix should be dilated until it will admit the operator's finger, and the interior of the uterus explored by touch, all adventitious tissue being removed either with the finger, curette, or curette forceps, and preserved in a ten- per-cent formalin solution for microscopic examination. Chronic Non-gonorrheal Endometritis Varieties. — Chronic endometritis may be divided into: (1) those forms of acute endometritis that have terminated in a chronic form, and (2) the varieties which present no acute stage demonstrable by clinical methods. (1) The forms of acute endometritis which have become chronic are commonly of puerperal origin, or post-abortum. Some of the pathological varieties are, — pseudodiphtheritic, decidual, and ulcerative endometritis. A chronic endometritis resulting from an acute septic endometritis generally has as complications one or more of the following affections: — metritis, cellulitis, peritonitis, pelvic abscess, or salpingitis. When the inflammatory process is centered chiefly in one of the situations just enumerated, the in- flammation of the endometrium is less active and the physical signs indicate that in the endometrium the fire has, as it were, burned out, leaving only smouldering embers. Microscopic examination of the endometrium reveals one or more of the different stages of glandular and interstitial endometritis as described on pages 170 and 171. CHRONIC XOX-GOXORRHEAL EXDOMETRITIS 177 If septicemia is present the symptoms are those of chronic septicemia; fluctuating elevations in the temperature, rapid and feeble pulse, dry skin, diarrhea, the odor of sepsis, malnutrition, and anorexia. There being no septicemia the symptoms are leucorrhea, uterine hemorrhages, menstrual disturbances, clyspareunia, sterility, and abortion, and symptoms referable to the digestive and nervous systems. Leucorrhea is the only constant symptom. The discharge is profuse, — though varying in amount in individual cases. It is purulent in character and may be mixed with blood. It is, as a rule, odorless unless it has been retained on the vulva and has decomposed because of the patient's uncleanly habits. A history of an acute attack of septic infection and the character of the leucorrhea — especially if septic microorganisms can be found in it upon microscopic examination of cover-glass prepara- tions— serve to distinguish this form of endometritis from (2) The large number of varieties of chronic endometritis which are not preceded by a known acute stage. They may be enumerated as: — fimgous, villous, polypoid, exfoliative, and tuberculous. The endometritis of the infectious diseases — typhoid fever, diphtheria, scarlet fever, measles, small-pox, and syphilis — all are of a mild type. Etiology. — Predisposing causes of chronic endometritis are: — uterine displacements, uterine malformations (especially ante- flexion), subinvolution of the uterus, extensive lacerations of the cervix, tumors of the pelvis, sexual excesses, chronic constipation, the infectious diseases, and certain constitutional diseases, — anemia, chlorosis, rheumatism, and lithemia. The pathological processes present are glandular and interstitial endometritis as described on pages 170 and 171. Symptoms. — The chief symptom is leucorrhea. The patient does not remember when she first noticed a vaginal discharge, so gradual is its beginning. It is due to the secretion of the utricular glands plus that of the vulvovaginal glands. The amount depends on the condition of the endometrium, — more when it is hypertrophied and in the glandular variety of endometritis, and less in the atrophic variety. In the fungous and polypoid forms the leucorrhea is apt to be bloody, and, if there is decomposition of tissues, purulent. In 12 178 THE DIAGNOSIS OF ENDOMETRITIS most of the varieties of chronic endometritis the discharge is thin and serous in character. When the secretion from the cervical canal exceeds in amount that from the body of the uterus the discharge is thick and viscid in consistenc}^ It is without odor and is unirritating as a rule, although in patients of uncleanly habits it may have a foul odor. The amount of discharge varies from a staining of the linen to several well-soaked napkins a day; it is increased for a day or two just before and just after each menstrual period because of the normal congestion of the genital organs at these times. Hemorrhage at the menstrual period or excessive menstrual flow — styled menorrhagia — is to be expected in the hypertrophic form of endometritis; scanty flow in the atrophic forms. Painful menstruation — dysmenorrhea — is a pretty constant symptom, although it occurs in such great variety of manifestations and at such variable times with reference to the flow that it is impossible to dogmatize about it. Irregularity in the occurrence of menstruation also is to be expected, variations of a few days before or after the normal time being common. Sterility and abortion are more often observed in patients suffer- ing from chronic endometritis than in women with normal uterine organs. Symptoms of general ill health usually accompany chronic endometritis, although it is not always easy to determine whether the ill health is due to the endometritis or the endometritis to the ill health. Signs. — The physical examination reveals a uterus enlarged, but not necessarily to a marked degree, and more or less sensitiveness of the uterus to light pressure when it is squeezed between the ex- aminer's fingers during the combined vagino-abdominal or recto- abdominal touch. If the uterus is occupied by polypi it will be felt to be fatter than normal, and often a polypus, having been elon- gated and driven down b}7 the uterine pressure, presents at the external os. On speculum examination a discharge is seen to be issuing from the external os. Its character is noted. A tough stringy mucus is the characteristic of the secretion of the glands of the cervix; a thin, watery discharge is from the glands lining the cavity of the corpus uteri. The alkalinity of the discharge should be tested ENDOMETRITIS AND GONOCOCCUS INFECTION 179 with a piece of litmus paper. In endometritis the reaction is often neutral or even acid. The condition of the neck of the uterus is noted, — whether lacerated or eroded or not. On passing the uterine sound the cavity of the uterus is generally found to be enlarged. In anteflexion with endometritis the in- ternal os is tight, but the operator will find that by straightening the canal by traction on the cervix with a tenaculum it is always possible to pass a sound of small caliber. Previous to passing the sound an accurate idea should be obtained as to the probable direction of the uterine canal by means of the bimanual touch. Great gentleness is essential. If the sound is passed with the greatest care and blood flows after its withdrawal and the cavity is tender, endometritis may be diagnosed. Fungosities and polypi are to be detected in favorable cases by the tactile sense transmitted through the sound, i.e., when the canal is widely open and reasonably straight. Points of ten- derness in the endometrium and their definite situations are deter- mined by the sound. Gonorrheal Endometritis and Gonococcus Infection Gonorrheal endometritis merits special consideration because it is a very common disease and has serious sequelae. As to its frequency authors do not agree. It is undoubtedly more common in the public clinics and among prostitutes than in private practice. Zweifel estimated that ten per cent of his private gynecological cases suffered from gonorrhea. Different writers place gonorrhea as the cause of acute inflammation of the uterus and tubes in from one-half to two-thirds of the patients seen in the dispensary services of the large cities. This estimate includes some of the puerperal cases, which form a considerable number of the total acute infections, for the gonococcus, as well as the staphy- lococcus and the streptococcus, is the cause of puerperal infection. The gonococcus, a diplococcus discovered by Neisser in 1S7(.), finds a favorite habitat in the deeper portions of the mucous mem- branes which are covered with cylindrical epithelium. It also grows readily under pavement epithelium, but can not penetrate the squamous epithelium as easily as the columnar. Its favorite homes in the female generative apparatus when once 180 THE DIAGNOSIS OF ENDOMETRITIS introduced are, in order of frequency: — (1) the urethra and Skene's and Bartholin's glands; (2) the mucosa of the cervical canal; (3) the upper portion of the vagina; (4) the endometrium of the corpus uteri ; (5) the mucosa of the Fallopian tubes. Although the squamous epithelium of the vagina of adults, bathed in its acid secretions and protected by its normal bacterial flora, resists the invasion of the gonococcus, the tender vaginal mucosa of children, although covered by squamous epithelium, is easily penetrated by it, whence the frequency of vulvo-vaginitis among children. The gonococcus is speedily destroyed by other bacteria and their toxins in the case of a secondary infection in the process of abscess formation, as attested by the rarity with which it is found in the contents of a chronic pyosalpinx; on the other hand it may remain alive in the mucosa of the cervical canal or in Skene's glands for a series of years. As a rule gonorrheal infections are uncompli- cated by mixed infections with other bacteria unless trauma accompanies the infection. The diplococcus is always introduced from without — in little children by the contaminated fingers of an adult infected with the diseases and by soiled linen or bath sponges — in adults, as a rule, by coitus. Gonorrheal endometritis invariably begins in the cervical canal. It may be limited to the cervix uteri if the internal os is well closed, — as in virgins and in anteflexion. In muciparous women it is prone to spread to the corpus uteri. Sometimes the gonococcus is carried from the cervix to the corpus uteri by the physician's sound or uterine applicator. The disease is acute or chronic. Acute Gonorrheal Endometritis The disease is limited to the cervix, acute gonorrheal endocer- vicitis. The mucosa of the cervical canal is reddened, swollen, and bathed in pus, which sometimes has a greenish tinge. The neck is swollen, soft, and tender to the touch. Examined histologically the mucosa shows loss of epithelium in places; the uterine glands show hypertrophy and hyperplasia, and the interglandular tissue is enormously infiltrated with round cells and polymorphonuclear leucocytes. The blood-vessels arc increased in number and size. ACUTE GONORRHEAL ENDOMETRITIS 181 On staining for the gonococcus it is found lying in groups between the epithelial cells and also in the subepithelial tissue. The gonococci may also be found in the pus. They seldom penetrate the uterine muscle by way of the lymphatics as do the streptococci, and when gonorrheal inflammation reaches the peritoneum it does so by way of the mucosa of the corpus uteri and of the Fallopian tubes. Symptoms. — The symptoms of acute gonorrheal endocervicitis are generally marked by the symptoms of coincident inflammation in the urethra, vulvovaginal glands, and vagina. There is a history of infection. The symptoms are ushered in by a chill followed by an elevation of temperature and a rapid pulse. The patient com- plains of pelvic pain, painful micturition and defecation, nausea and vomiting, and, in the course of a few hours, there is a leucorrhea, — at first mucous in character, soon becoming purulent and some- times mixed with blood. The symptoms are not so severe as in acute septic endometritis, and last not over a week. They are more pronounced if the inflammation has extended to the body of the uterus, and still more so if to the Fallopian tubes. In these cases one looks for greater pelvic and abdominal pains. Diagnosis. — The diagnosis rests on (1) the history of a suspicious intercourse, which was followed by a purulent vaginal discharge, and by preceding frequent and painful micturition, i.e., an acute urethritis, strong presumptive evidence of gonorrhea; (2) the symptoms just enumerated; (3) the physical signs. The cervix is swollen and tender, and pus flows from the os. If the mucosa of the corpus uteri is also involved — acute gonorrheal endometritis — the entire uterus is enlarged and tender to bimanual touch; (4) the microscopic examination of the pus shows the presence of the gonococcus. Differential Diagnosis. — The acute form of gonorrheal endome- tritis may be mistaken for acute septic endometritis. In the gonorrheal form the local and constitutional symptoms are less severe, there is lacking a cause for sepsis in the form of post-puer- peral infection or intra-uterine treatment, and on the other hand there may be presenl a history of a suspicious intercourse. The urethra, Skene's glands, and the vulvo- vaginal glands are involved; there may be enlargement of the lymphatic glands of the groin- adenitis, bubo — finally the gonococci are found in the discharge. 182 THE DIAGNOSIS OF ENDOMETRITIS Chronic Gonorrheal Endometritis Chronic gonorrheal endometritis may result from a well-marked acute gonorrheal endometritis. More commonly the history of an acute stage is wanting. The history of frequent and painful micturition, either following marriage or in a woman suspected of having loose habits, whether married or single, should lead the physician to consider the possibility of gonorrhea. The onset of the disease is generally insidious; the symptoms and physical signs are those of the varieties of chronic endometritis due to the saprophytic and pyogenic bacteria. The leucorrhea in gonorrheal endometritis is generally most abundant; it loses the purulent character of the acute stage and is mucous in character. The diagnosis depends on finding the gonococcus in the discharge from the cervix. Some authors claim that it is necessary to make cultures in order to identify surely the microorganism, but this view is not held by most. Many slides should be examined. Negative findings do not rule out gonorrhea, and this brings us to the consideration of latent gonorrhea. Latent Gonorrhea in Women. — Certain experiments by Wertheim of Vienna (Archiv. fur Gyn., 1892, XLL, No. 1), and clinical observations by a number of investigators, go to show that the gonococcus loses its virulence after a time — weeks or months — that when it is planted in new ground, i.e., when another indi- vidual is infected, the microorganism recovers its former vitality, and that when reintroduced into the original host all the symp- toms and signs of an acute attack of gonorrhea are manifested. For example, a man has acute gonorrhea which ends in a chronic gleet. He infects his wife and later is reinfected by her and has another acute attack of gonorrhea. In the course of time each becomes tolerant of the gonococci of the other. The husband has intercourse with a prostitute, suffers a fresh attack and reinfects his wife. This explains why