Endometrium

“ 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. ”

“ 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. ”

“ The focus of continuous irritation in the cervix interferes with the normal involution of the body of the uterus, so that there occurs a condition of uterine subinvolution, which may be the cause of the chief symptoms with which the woman suffers. The endometrium shares in the subinvolution, and, as a consequence of this, and perhaps also from extension of inflammation from the cervical mucous membrane, various forms of endometritis may occur. ”

“ DIAGNOSIS.—The symptoms resemble closely in kind, but differ in degree from, the appearances in acute metritis. The uterus is smaller and not so painful on pressure. The endometrium is sensitive to the slightest touch—a fact elicited upon the passage of the sound. The characteristic symptom is the discharge from the uterine cavity of a more or less profuse secretion possessing the character already mentioned. An absolute differential diagnosis is impossible, nor is it necessary, seeing that the treatment of the two conditions is nearly identical. ”

“ The most satisfactory method of dealing with cancer arising in the corporeal endometrium consists in performing total abdominal hysterectomy (see p. 40) , removing not only the uterus and its neck, but both ovaries, Fallopian tubes, mesometria, and any enlarged lymph glands that are detected. In the course of the operation the surgeon should avoid any undue handling of the uterus, and, in withdrawing it from the pelvis, care should be taken not to infect the operation area with any fluid or semi-fluid stuff which is liable to escape from the cervical canal. ”

“ 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. ”

“ The uterus diminishes in size; the vaginal cervix may disappear; the utricular glands diminish in size and number; the endometrium atrophies. The Fallopian tubes shrink and become shortened, and the fimbriæ disappear. Similar atrophic changes affect the vagina, the external genitals, and the mammary glands.
If the woman is in good general health, and has no disease of the uterus, the tubes, or the ovaries, the menopause may become established without any marked general disturbance. ”

“ Pelvic inflammations, as cellulitis or pelvic peritonitis, give rise to the disease. Affections of the uterus are frequent causes; displacements, as retroversion or prolapsus; and inflammation, either parenchymatous or of the endometrium. Quite a moderate grade of inflammation, as found during the interval, may, under the increased congestion of menstruation, become extreme. Many cases doubtless depend upon an ovarian influence even when no affection of these organs can be made out. ”

“ When the endometrium is septic or cancerous both ovaries and tubes should be removed. When the surgeon decides to leave an ovary and its corresponding Fallopian tube, he should take care in securing the ligatures to include the ligament of the ovary: it is very liable to slip out of the encircling loop of silk. It is often convenient to include the round ligament of the uterus in the pedicle, but it is not a disadvantage when it is tied separately. ”

“ The rectum and bladder are subject to inflammation and chronic catarrh, and the bladder especially to concurrent descent. The uterus may be enlarged from any one or all of a variety of causes—congestion, subinvolution, hypertrophy, and hyperplasia. Its cervix is often the seat of extreme erosion or so-called ulceration. The endometrium, in order to relieve the organ of its surplus blood, gives forth an excessive secretion of mucus, which upon being increased in quantity becomes vitiated in quality. ”

“ Thorough curetting of the cavity of the uterus is the most certain method of controlling the hemorrhage. By this procedure the diseased endometrium is removed, and the bleeding is usually very decidedly diminished for several months afterwards.
The treatment by electricity, once popular with some physicians, has not stood the test of time and experience. It does not stop the growth of the tumor. It has caused 252 many deaths. It may produce peritoneal adhesions, which render subsequent operation most difficult. ”

“ The hæmorrhage from fibro-myoma of the uterus may require removal of the endometrium in order to relieve the bleeding temporarily at any rate. When milder measures fail, curetting is of great service in arresting the profuse menorrhagia which so often accompanies subinvolution of the uterus. ”

“ Under judicious treatment disappearance of the more distressing symptoms may be confidently expected during the stage of infiltration. The outlook is especially favorable in cases of puerperal subinvolution in the absence of chronic inflammations of the endometrium and parametrium. A perfect restitution of the uterus to its normal condition is so seldom effected by any rational therapy that for practical purposes this desirable result may be excluded from consideration. Recidiva of the disease are liable to occur at any time. ”

“ This disease has not received adequate recognition at the hands of British surgeons, yet it is a condition which occasionally causes much doubt in the surgeon’s mind in the course of hysterectomy. This adenomyomatous change affects the endometrium and is, in some cases, associated with interstitial and subserous fibroids: it causes often great enlargement of the uterus, and under these conditions the fundus can be felt high in the hypogastrium. The patients are often profoundly anæmic as the result of long-continued menorrhagia. ”

“ Consequently, in performing subtotal hysterectomy for fibroids in women of fifty years and upwards, the surgeon should have the uterus opened immediately after its removal and assure himself that the endometrium is free from cancer. ”

“ The uterus is covered, front and back, by a fold of the peritoneum, except the lower part of the anterior wall where the peritoneum is reflected up over the bladder. It is lined with a thick, velvety, highly vascular mucous membrane, the endometrium, the surface of which is covered by ciliated, columnar epithelium. ”

“ The effect of repeated coition, provided that impregnation does not take place at once, is to engorge the uterine vessels, to alter the nature of the glandular secretions, to cause profound reflex disturbances, and thus to produce such changes in the endometrium as to lead to local inflammation and to general nervous exhaustion. ”

“ The mucous membrane of the cervical canal may be the seat of acute or chronic inflammation. Acute inflammation usually occurs as part of a general acute process affecting the whole of the endometrium, and is commonly the result of gonorrheal or septic infection. It will be considered under General Endometritis.
Chronic inflammation of the mucous membrane of the cervical canal (cervical catarrh or cervical endometritis) is an exceedingly common affection. Unless caused by gonorrhea, it is nearly always secondary to some local or general condition. ”

“ Frequent abortion in the early months. Curetting often cures this by removing the diseased endometrium.
(v) Inoperable carcinoma of the cervix. Removal of the redundant portions of the growth by the curette, followed by cauterization or other measures, relieves the hæmorrhage and foul discharge. Great caution must be exercised, lest the peritoneum or bladder be opened into by the curette and the sufferings of the patient thereby increased. Cells of the disease may also be pushed into the pelvic lymphatics; considerable febrile disturbance may also follow the operation. ”

“ The albuminoids of the muscular protoplasm are not so readily converted into fat capable of easy resorption. A comparatively large quantity of decidua vera—even in the absence of portions of the foetal envelopes—is retained within the uterine cavity, and the secretory activity of the endometrium is seriously disturbed. Then, women are less careful after miscarriages than labor at term.
Laceration of the cervix uteri—an accident liable to occur in abortion as well as during confinement at term—if at all extensive, usually interferes with the retrograde metamorphosis of the uterus. ”

“ The monthly general congestion of the genital organs, necessary for the ovum to leave the Graafian follicle, also causes the uterine mucous membrane to swell from one85 to three millimeters in the thickness.G The mucosa becomes thus turgid and velvety. The epithelial cells of the endometrium swell and multiply. The openings of the uterine glands are enlarged, and a whitish, opaque mucus is poured out. The glandular cells are enlarged, and there is a multiplication of the round cells of the stroma. The cells are cloudy and filled with fat granules. ”

“ The tendency is to recovery with more or less protracted convalescence. The most serious complications are extension of the disease and later sterility. Rest in bed and intrauterine irrigation, followed by the introduction of iodoform pencils into the uterine cavity, should be resorted to, while pain is relieved by hot fomentations and sitz baths. Chronic endometritis may be the sequela of the acute form, or may be septic in origin, or the result of chronic congestion, acute retroflection or subinvolution following delivery or abortion. ”

“ The uterus is usually found to be larger than the atrophy general at the patient’s age would have led us to expect, it is often retroflexed, the cervix is thickened, the lips of the os uteri are usually everted and raw. When persistent, this senile endometritis causes profound constitutional disturbance, and is often difficult to differentiate from carcinoma of the uterus. ”

“ To sum up the normal pregnancy, we find that in the course of ten lunar months, following the fertilization of an ovum, the uterus grows from a small, flattened, pelvic organ, three inches in length, to a large, globular, muscular sac, constituting an abdominal tumor about fifteen inches long; it increases its weight thirty-two times, that is from two ounces to two pounds, while the capacity of the uterine cavity is multiplied five hundred times. Within the cavity is a child weighing about seven and a quarter pounds, surrounded by a quart or so of amniotic fluid. ”

“ An increase in the size of the uterus, from increase in the amount of blood, is frequently noticed at the beginning of the menopause; later it becomes smaller in all its dimensions. The wall becomes thinner; the cervix becomes shorter and thinner, sometimes hard, sometimes flabby as a membrane. But the distinguishing feature of the menopastic uterus is atrophy of its lining membrane.
The changes in the uterus and Fallopian tubes are earlier than those in the ovaries, so that ovulation, though lessened in activity, may persist for a considerable time after menstruation has ceased. ”