PART II SPECIAL DIAGNOSIS (Part 3)

the gonococcus, even after years of apparent cure, may regain its full virulence. Such authorities as Wasscrmann (Bed. Klin. Woch., 1897, No. 32, p. 685), Maslovski, DeChristmas, and Jullien agree that there is no immunity in gon- orrhea, one attack giving no exemption from the disease in the future. It argues for repeated examinations of a gleety urethral discharge in the male before advising marriage. SENILE ENDOMETRITIS 183 The cervical canal and Skene's glands in the floor of the urethra are the chief lurking places for the gonococcus in the female genital apparatus. Differential Diagnosis of Chronic Gonorrheal Endometritis. — Chronic gonorrheal endometritis may be mistaken for the simple forms of endometritis. A gonorrheal origin of an endometritis may be suspected from the history of the case ; — an acute attack with purulent discharge and painful micturition following a sus- picious intercourse. Occasionally there is a history of the patient having had a bubo or gonorrheal inflammation of the joints. More commonly no such history is obtainable. It is seldom advisable to institute too minute inquiries in this direction in the case of married women because of the risk of causing trouble between husband and wife, — trouble which can not be cured by the physician. Tubal disease is found in conjunction with all forms of endome- tritis, but more commonly with the septic and gonorrheal forms. In most cases repeated bacteriological examinations of the dis- charge from the cervix are the only way of distinguishing to a certainty the cause of the inflammatory process. The results of the examinations are so often negative that we are left with only a probable diagnosis founded on the history alone. Senile Endometritis Senile endometritis is an atrophic form of endometritis occurring in women who have passed the menopause, occurring particularly in poorly nourished subjects. It is due to the infection of the atrophying mucosa, but what causes the infection is not known. Pathologically the endometrium is found thinned, the glandular elements are wanting, and many times the endometrium is entirely replaced by connective tissue. There may be stenosis of the uterine cavity from adhesion of the walls, and, from the same cause, the retained secretions may form a senile pyometra or hydrometra. The latter is very rare. The symptoms have an insidious ousel, a thin, purulent, often offensive and irritating vaginal discharge being the chief symptom. Pruritus vulvae is common, also vulvitis. Sometimes the discharge is tinged with blood. There may be symptoms of mild sepsis if the discharges are retained, and in this case pelvic pains are to be expected. 184 THE DIAGNOSIS OF ENDOMETRITIS The physical signs show the uterus to be small (unless there is pyometra) , and the cervix uteri is atrophied. An attempt to pass the sound will reveal partial or complete atresia of the uterine canal. If the canal is patent the discharge is seen issuing from the os. The disease, coming as it does after the menopause and attended as it is by a foul discharge, may be mistaken for carcinoma of the cervical canal or body of the uterus. Dilatation and curetting, with an examination of the tissue removed, will settle a doubt. Endocervicitis Endocervicitis is a chronic inflammation of the mucosa of the cervical canal. It is called also cervical catarrh and cervical endometritis. The disease is confined to the cervix uteri, — there is no extension to the mucosa of the corpus uteri. This is a common affection. The gonorrheal form has been described under chronic gonorrheal endometritis. Lacerations of the cervix are a frequent cause. When the cervix is torn the lips become everted and are subjected to trauma from (1) pressure on the posterior wall of the vagina by scybalous masses in the rectum resting on the unyielding sacrum, or (2) from excessive coitus. Another common cause of endocervicitis are polypi originating either in the mucosa of the cervix or corpus. The cervical tissues in endometritis become hypertrophied, the mucosa is eroded, and cystic degeneration develops. Infection is difficult to dislodge as the bacteria occupy the glandular crypts. Erosions of the Cervix Uteri Characteristics. — Erosions of the cervix uteri are characterized by a dark red or purplish color of the tissues immediately around the external os uteri. Having the appearance of ulceration they were formerly believed to be true ulcers. In an erosion there is no inflammatory action accompanied by destruction of the epithelium as in ulceration. The surface squamous epithelium, which normally covers the cervix, is re- moved,— it is eroded, — and the underlying columnar epithelium is hypertrophied. (1) A simple erosion presents a uniformly smooth, velvety surface EROSIONS OF THE CERVIX UTERI 185 with sharply defined edges. On microscopic examination it is seen to consist of a single layer of columnar epithelium with little or no formation of new glands. (2) A papillary erosion has an irregular projection of its livid red surface and has been called "cock's-comb granulations." Here the microscope shows deep invaginations of the columnar epithe- lium to form glands, alternating with elevations made up of newly formed connective tissue and round cells. The glands secrete a viscid mucus. (3) A follicular erosion is one in which retention cysts — the so- Fig. 69. -Erosion of the Cervix with Lacerations. (H. Macnaughton- Jones.) called Nabothian follicles — are present in considerable number. These cysts are formed by the occlusion of the newly formed glands referred to in the description of the papillary erosion. They are filled with inspissated mucus and vary in number. There may be half a dozen, or the cervix may be fairly riddled with them. In size they vary from a B.B. shot to an English walnut in extreme cases. They are usually not larger than a pea. To the examining finger the retention cyst feels like a shot; to the eye it appears as a little rounded elevation of a bluish-white or yellow color. Diagnosis. — Leucorrhea is the constant symptom of endocervi- citis. The diagnosis is made by digital and speculum examinations. The finger detects lacerations, the soft velvety surface of the 186 THE DIAGNOSIS OF ENDOMETRITIS erosion, the stringy plug of mucus in the os, shot-like retention cysts, and tenderness of the tissues of the cervix. The speculum shows the scars of the lacerations and thus their extent, the dull red roughened surface of the erosion, the plug of mucus in the os, polypi, and retention cysts, if they exist. The fact that erosions are found in the virgin and even in the infant (see Chapter XXVIII. , page 563) must be borne in mind. The determining factor in the causation of this condition seems to be the exposure of the columnar epithelium with which the canal of the cervix is lined to the conditions which obtain in the vagina where the mucous membrane is paved with squamous epithelium. Differential Diagnosis. — The differential diagnosis concerns itself with the exclusion of ulceration due to (1) an ill-fitting pessary, (2) to tuberculosis; (3) to chancre or chancroid, and (4) to carcinoma. All forms of true ulceration are rare, — erosions are common. (1) Ulceration from an Ill-fitting Pessary. — If an ill-fitting pessary has been removed and the ulceration does not promptly heal under appropriate treatment a piece of tissue should be excised under cocaine anesthesia and examined microscopically. (2) Tuberculous Ulcer. — Evidences of tuberculosis elsewhere in the body, a history of tuberculosis, and microscopic examination of the discharge and a piece of excised tissue, will establish the diagnosis. (3) (a) Chancre. — The history is an important consideration. A definite period of incubation of the disease is present and the symptomatology and signs are those of syphilis. Chancre is seldom seen in the initial stage, i.e., before ulceration. When ulcerated it is a single ulcer. The ulcer heals under antisyphilitic treatment. The differentiation of the Spirochsota pallida in a piece of tissue removed for microscopie examination makes the diagnosis certain. (b) Chancroid. — Here one finds multiple ulcers appearing soon after a suspicious intercourse and no symptoms of syphilis. (4) Carcinomatous Ulcerations. — These are generally attended by much thickening of the surrounding tissues and bleeding. A piece of tissue should be excised and sent to the pathologist for microscopic examination.