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closely attached to the neoplasm, it is often difficult to find, and still more trying to remove, lateral incisions through the abdominal walls being occasionally required (K. Schroeder). The operation must often even be left unfinished. The mortality is over 15 per cent., and the desired result fails in 20 per cent. of those cases not immediately fatal. The value of castration for unoperative uterine myomata therefore remains sub judice, and its value, when compared with myomotomy, cannot be definitely determined with our present limited experience.

CHAPTER IV.

NUTRITIVE DISTURBANCES OF THE UTERUS.

1. THE INFLAMMATORY DISEASES OF THE UTERINE MUCOUS MEMBRANE. ENDOMETRITIS.

Pathological Anatomy. - In acute endometritis the uterine mucous membrane is abnormally congested, reddened, swollen, containing occasional small extravasations, and is more easily separated from the subjacent tissue than when normal. It at first pours out a serous or sero-sanguinolent secretion which later becomes clouded, thicker and purulent, and which contains the débris of cylindrical cells, and exfoliated epithelium from the cervical and uterine glands. This thick, tenacious cervical secretion rapidly disappears, and is followed by an increased discharge which may become quite profuse. After some days the secretion and hyperemia diminish, the swelling disappears, and the newly formed ciliated epithelium restores the surface to its normal condition, while the extravasations and transudations into the mucous membrane are absorbed. But if recovery does not take place, the acute variety passes into a chronic endometritis; the two may be described together. The mucous membrane remains thick and flabby in the chronic stage; the former extravasations change to yellowish or dark-brown spots; the inner surface is smooth or uneven, ridged, wavy or nodulated, depending upon

the portion chiefly involved. C. Ruge classifies endometritis into the glandular, the interstitial, and the mixed form.

In the glandular form there is proliferation of the glandular epithelium, and the normally smooth gland tubule has a serrate appearance upon section, and corkscrew-like convolutions may appear. Ruge further describes two subdivisions of glandular endometritis, viz., the hypertrophic and the hyperplastic. In the former the glands are not increased, but simply diseased; in the latter they are increased in number, either by the formation of diverticuli in the old glands, or by new depressions in the surface of the mucous membrane.

The diseases in which the stroma of the mucous membrane is chiefly affected, and which are likewise comprised under the name of interstitial endometritis, have also various forms, according as to whether the cellular elements or the connective tissue are chiefly involved. It is said that the round cells, which have a large nucleus, are transformed into fusiform cells with an oval nucleus, and that they increase in size and interlace in all directions. They thus become similar in appearance to the decidual cells.

When the stroma is especially involved, the tumor grows larger, is either softer or indurated and more brittle.

In the combined form the glands and the stroma are affected, though not in the same degree, the interstitial proliferation usually predominating, while the glands show moderate hyperplasia, and are either generally dilated, or else constricted in some places and dilated in others.

When the inflammatory process is long-continued, the mucous membrane finally atrophies and becomes thinned, the cilia are lost, the gland cells or even the entire glands disappear, and at last the only covering to the inner surface of the uterus is a thin, smooth layer of connective tissue.

All these varieties may become circumscribed or diffused, and be of a severe or a mild type.

In the puerperal state, or especially after abortion or premature delivery, the interstitial form is usually the primary stage, the glands becoming implicated later. Islands of decidua act as

irritants and cause abundant small-celled proliferation in the surrounding mucous membrane.

Hitherto we have spoken of disease of the mucous membrane of the body, but the cervical surface will necessarily become affected later, since the irritating discharge flows over it in passing from the uterus. The swelling presses the pavement epithelium of the vaginal portion outward until it appears in the vault; it is exfoliated, and the cylindrical layer beneath it exposed. At the same time the mucous membrane becomes hypertrophied through the formation of folds and glandular inversions; these may penetrate the mucous membrane and even press into the muscular tissue beneath.

Simple erosions are said to be formed when the dark-red, glossy surface of the cylindrical epithelium appears upon portions of the surface where pavement epithelium is usually found. When numerous and uniform new gland inversions arise, the remnants of tissue between them are said to resemble papillæ, with which they have really no connection; hence the name papillary erosions, for which a more appropriate term would be papilloid. When retention of fluids takes place in these glands the dilatation and constriction lead to the formation of small cysts, the so-called follicular erosions.

The muscular tissue of the cervical wall not infrequently becomes involved in this affection of the mucous membrane, its structure growing irregularly hypertrophied, rough and uneven.

In nulliparæ chronic cervical catarrh often causes stenosis of the external os, and also dilatation of the lumen of the cervix by a thick, tenacious, firm plug of mucus. The surface of the external os shows simple erosions, while higher up the mucous membrane contains diverticula, is beset with small cysts, and in the later stages becomes rigid and thickened, or attenuated and reticulated.

The contents of the distended cervical glands exert a constant irritation upon the wall of the glands; inflammation results and abscesses are often formed. These abscesses may be developed about the whole periphery of the os, but are most common on the anterior lip. They rupture after growing to the size of a pea or bean, and after evacuation of the pus the surface of the vaginal portion

becomes uneven and sinuous, so that the resulting cicatrization may leave some loss of substance. When the vagina is likewise diseased, the purulent secretions penetrate still further into these depressions, often resulting in obstinate ulceration of the lips of the uterus.

In rare cases the lower segment of the uterus becomes œdematous, but the oedema is transient and usually confined to one lip; the oedematous lip may appear lobulated. The oedema is most marked in acute infectious catarrh. In severe chronic catarrh, phlebectasis may be developed; it is probably both the cause and the effect of the catarrh, and more deeply seated than may at first appear. Varicose ulceration, similar to that occurring upon the lower extremities, may result from rupture of the walls of these veins. The edges of the ulcers are firm, irregular, undermined, and sometimes contain ecchymoses; the surface of the ulcer is doughy, bleeds easily, and the vaginal portion is livid, and bluish-red in color.*

Symptoms. In cervical catarrh the normally viscid secretion is increased in amount, is thinner, and clouded with mucus and pus. It is often streaked with blood, which exudes from the hyperemic tissues, and the distended tense mucous membrane is painful, and causes a feeling of internal heat and distressing throbbing. The pains are like those of the first stage of labor, and are chiefly sacral, shooting into the external genitals. Through the long-continued leucorrhoea the patient grows irritable and hypersensitive, and the congestion causes a more profuse menstrual flow, which increases the weakness and enervation. Cohabitation is distressing and is seldom followed by conception. A viscid mucus, which collects in the cervical canal, is, in many cases, the cause of the dilatation, the latter not being due solely to the elongated and thickened mucous membrane, and this is evident from the uniform globular distension of the cervix.

In acute endometritis of the body of the uterus there is at first a slight fever, with a feeling of internal heat and bearing-down, which are communicated to the bladder and rectum, causing some tenesmus. The discharge is thin, serous, and afterward

* Heitzmann, 1. c., p. 150 ƒ, fig. 19, and plate ix., fig. 5.

purulent; palpation of the uterus is not especially painful, but the introduction of the sound, particularly through the internal os, causes suffering. The abnormal secretion in chronic endometritis as, indeed, the healthy secretion, is not yet well understood. B. S. Schultze endeavored to diagnosticate purulent endometritis by finding pus upon a tampon which he had firmly packed against the lips of the uterus. Schröder denies that this is a proof of the pus coming from the cavity of the uterus, meaning, of course, that it may come from the cervix as well. I do not believe that even microscopical examination can decide this difficult question, for the inflammation destroys the cilia of the epithelium and alters the form of the cells. But I am convinced, as Schröder also maintains, that the secretion of the mucous membrane of the uterus is slight in amount, and, as a rule, serous or sero-sanguinolent. But that it may become more profuse at times, is shown by the discharge of a considerable quantity after reposition of the retroverted or retroflexed uterus, the secretion having evidently been retained in the organ, thus producing slight hydrometra. When the disease is severe and the swelling great, there may be intermenstrual hemorrhages at irregular intervals, and during menstruation there are pains of varying duration and intensity. At times the pain is more severe when the flow appears, and ceases with the discharge of a quantity of mucus, or fragments of the membrane, endometritic exfoliation, or when the flow of blood is more profuse and unobstructed. There may be paroxysms of shooting pains in the abdomen, sacral region, or in the mammæ, during the intervals of menstruation, which diminish in severity with the appearance of a discharge from the genitals. The pains may extend into the thighs, or along the course of the sciatic or anterior median cutaneous nerve, and are often persistent. When the disease passes through the uterine walls into the contiguous tissues, or more especially into the posterior ligaments of the uterus, a posterior parametritis results, the effects of which, with regard to the position of the uterus, have already been considered.* The process very often extends to the Fallopian tubes, especially in infectious blenorrhoea; then

* Vide pp. 311-317.

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