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S. (Samuel Jean) Pozzi.

Treatise on gynæcology : medical and surgical online

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easily scraped off with the curette which cannot penetrate the mus-
cular layer unless it is much softened by inflammation, which is
very unusual.

Hardened in alcohol, to fix the different elements, and cut in
microscopic section, it is easily seen that the mucous layer is abnor-
mally thick. When stained by picro-carmine this thickening is very
plain to the naked eye. The mucous membrane then has a slightly-
yellow tinge, which distinguishes it from the redder muscular tissue.
It is, moreover, more transparent, especially in its deeper portions,
where the microscope reveals the presence of glands. To appreciate
these details by the naked eye it is enough to examine a section
stained by picro-carmine, holding it against the light; the mucous
membrane is seen to be 2 to 5 mm., even 1 cm. thick at times, whereas
its usual thickness is but 1 mm. Its surface, instead of being smooth,
is fungous, presenting alternate projections and depressions of a
flabby appearance. These fungosities have received the name of villi,
vegetations, etc., and the disease has been therefore termed villous,
fungous, granulating, or vegetating metritis. These vegetations are at
times very large, of a round and elongated form, and may become
veritable polypi, sessile or pedicled. In other cases there are small
cysts, of the size of a pin's head, resembling the ovules of Naboth, so
common in the cervix and about the os externum, and having the
same glandular origin ; but they differ from these in the quality of
the fluid contained. It is more thin and serous, less consistent and
colloid, than the contents of the Nabothian ovules of the cervix.



THE PATHOLOGY AND ETIOLOGY OF METRITIS.



141



These small cysts of the body of the uterus are seen more often in
aged patients than in the young.

" Such is the macroscopic appearance of the uterine mucous mem-
brane after chronic inflammation." 6

In the histology of the subject there are three distinct types, often
clearly presented in different subjects or at times combined in one.
In this description I follow Wyder's recent work. 15

Chronic Interstitial Endometritis. — The interglandular tissue
which we have seen gorged with cells in the acute form so that it




Fig. 98.— Interstitial Endometritis ■with Partial Atrophy op the Glands (Wyder).

resembles granulation tissue, is transformed into true cicatricial tissue
in which the number of cellular elements steadily increases. The
glands undergo the opposite alteration, being strangled in places and
transformed into cysts, or so compressed in their whole extent that
they atrophy, and thus we may have a few glands scattered through
the connective tissue (Fig. 98), altered into cysts in places (Fig. 99,
A) or totally destroyed (Fig. 99, B).

In cases where the atrophy is very marked the muscular layer is
covered by only a very thin layer of sclerosed connective tissue and
this in turn by epithelium. Under the surface still covered by pave-
ment epithelium (Fig. 98), one sees the mucous membrane traversed



142



CLINICAL AND OPERATIVE GYNAECOLOGY.



by these fibrous layers wliicli frequently interlace to form a mesh-
work, generally filled with a homogeneous substance, though the
deeper portion of the tissue may be full of round cells packed
close together. Nearer the surface the interglandular tissue has a
more regular arrangement, being composed of a series of layers of cells
and their parallel prolongations. The section may contain only very
few glands.

At many points (Fig. 99) there are cystic cavities, lined with





Fig. 99. — Interstitial Endometritis with Complete Atrophy of the Glands (Wyder). A, Cystic
formation, last trace of glands; B, all vestige of gland tissue disappeared.



cuboidal epithelium and surrounded by bands of connective, tissue
with fusiform cells. At places there are evidently no glands present,
aud the mucous membrane is represented by a homogeneous connective
tissue which possesses no cells and is arranged in many bundles, the
whole being clearly marked off by a sharp line from the muscular
tissue. Near the surface this formation is smooth in places and at
others arranged in large flat villous projections. There are present,
therefore, all the signs of advanced connective-tissue sclerosis.

Chronic Glandular Metritis. — Ruge, and after him Wyder, rec
ognized two forms of glandular endometritis, the hypertrophic and



THE PATHOLOGY AND ETIOLOGY OF METRITIS. 143

the hyperplastic. In the first, the epithelial proliferation takes place
without multiplication of the glands themselves. Instead of being a
series of straight tubes, the glands are then of irregular form, fre-
quently twisted and arranged spirally. In the hyperplastic form there
is an increase in the number of the glands. Cornil 16 has discovered
karyokinetic figures in the epithelium lining the glands (Fig. 102) in
such cases. He is of opinion that this may be normally present after
menstruation, as it is a feature of physiological repair in gland cells.










V-i.



Fig. 100.— Glandular Endometritis op the Uterine Body I Wyder). Slightly enlarged.

Figure 100 presents a form of combined hypertrophy and hyper-
plasia which is more common than is usually supposed. The gland-
ular tissue is absolutely normal in structure, but the glands them-
selves are much distorted and have lateral prolongations.

Chronic Polypoid Endometritis. — This form is marked by an
enormous development of the mucous membrane, which has a fungous
appearance and may be bristling with small and soft polypi. Reca-
mier " was the first to give a good description of the macroscopic ap-
pearance in this form, and Olshausen has lately studied the subject
anew. It is a mixture, histologically, of interstitial and glandular
changes with marked cystic degeneration. On the surface the naked
eye discovers small vesicles of 1 mm. diameter, transparent and a little



144



CLINICAL AND OPERATIVE GYNECOLOGY.



elevated; and these under the microscope (Fig. 101) are plainly degen-
erated glands lined with cuboidal epithelium. They are separated by
bands of connective tissue; in the superficial layers the glands are




Fig. 101.— Glandular Endometritis, Polypoid Form (Wyder).

widely dilated, and more deeply they appear normal but are bent
aside, parallel or oblique to the muscular fibres.

The glandular culs-de-sac pass beyond their usual limit in the
depth of the mucous membrane and sink in between the subjacent



£



.-t



no )






*TL-



Fig. 102.— Epithelial Investment op a Gland from the Body op the Uterus (Cornil). X 350.
Reichert's apochromat. with 00.4. I, Nucleus with enlarging granules and filaments of nuclein; k, nucleus
showing the beginning karyokinesis, with "star 11 arrangement of nuclein; m, small, round wandering
cell between the cylindrical cells.

muscular fibres according to Cornil (Fig. 103). This is a remarkable
instance of what the older anatomists called " glandular heterotopy "
occurring with a simple inflammation having no tendency to become
malignant. In this invasion of the muscular tissue a certain amount



THE PATHOLOGY AND ETIOLOGY OF METRITIS. 145

of their investing connective tissue accompanies the glands. The
interglandnlar structure is very rich in vessels.

At the points which correspond to glandular dilatations, there are

fes ......



? i'H'' ? .



Q



?.,



41



life ■'■ ■ * ; - '■■■■'■ ' * : -







Fig. 103.— Glandular Endometritis (Coknil). x 40. Section showing the deep penetration of the
gland, a, Surface of mucous membrane, epithelium partly removed ; b. gland opening on the surface;
fir, glandular cul-de-sac deeply placed; t, connective tissue, new formed, with many lymph cells; ft, ft,
glands divided lengthwise, twisted, and dilated in places; m, muscular bundles between which the termina-
tion of the glands are seen.

inclosed numbers of spindle-shaped cells, whose prolongations give
the part a striated appearance, or, at other times, the tissue has very
few cellular elements; this latter arrangement is especially noticed



146 CLINICAL AND OPERATIVE GYNECOLOGY.

about the blood- vessels. Lying deeply about the intact glands among
the cysts there is found a homogeneous substance, replacing the
proper interglandular tissue, which is "full of round cells pressed
closely together (Fig. 101). De Sinety 18 has given an excellent de-
scription of the lesions of endometritis, although a post-mortem exam-
ination was made on but one case. He specially studied the vegeta-
tions and excrescences which are to be observed upon the mucous
membrane, and which he removed for the purpose by a Recamier's
curette ; but he laid less emphasis upon alterations in the membrane
itself. He describes three kinds of vegetation : the glandular, formed
by enlarged and distorted glands, with thickening of the connective
tissue ; the embryonal, formed of embryonic tissue and a few dilated
vessels; and the vascular, composed of vessels often widely dilated.

Certain authors discuss a diphtheritic metritis, which it were
better to call gangrenous, since the false membrane is merely the
product of a partial mortification. This is a simple nosological error
which has crept into the group, so well-defined clinically, of inflam-
mations of the uterus ; whereas it is but a simple accident which may
happen in the uterus or elsewhere, " in certain peculiar conditions
either general or local. Thus, diphtheritic metritis has been seen to
follow tamponade with perchloride of iron. 19 and to occur after enu-
cleation of a fibroma, or in the course of a septicaemia in an old woman
who had a phlegmon upon the lower extremity. 20 Cornil has also
observed certain details of high interest where the only change visible
is extreme enlargement, and the glands in longitudinal or cross section
present a single flat layer of cylindrical cells, usually on their internal
aspect. Where there are many layers superimposed, the details are
difficult to grasp, but sections sufficiently thin, if well examined, dis-
close only a single series of cells. The vibratile cilia which are found
upon normal glandular epithelium are in great part preserved, and
this retention of cilia in a gland so modified by chronic inflammation
is a remarkable fact. At the same time, it is not always easy to find
these cilia ; it is necessary to use for that purpose excellent objectives
and tissue absolutely fresh. To demonstrate them the material must
be taken as it comes from the surgeon's hands at the operation and
placed directly in some hardening fluid, preferably 90$ alcohol. In
preparations even of irreproachable freshness the cilia may seem to
have disappeared ; then there is seen upon the surface of the cell a
delicate layer of mucus, sometimes clear and homogeneous, at others
as if formed of little spheroid bodies, or somewhat striated, composed



THE PATHOLOGY AND ETIOLOGY OF METRITIS.



147



of an agglomeration of the cilia. The cells which fill the alveoli, often
completely, are identical with those found normally in the nterine
glands, cylindrical or modified, ovoid or even mncons.

The only difference presented by portions of tissue scraped off with
the curette and entire sections of the uterus, is found in the difficulty
of recognizing the relations of the first ; and therefore it is better to
study sections made perpendicularly to the surface in material pro-
vided by hysterectomy.

Finally, there is a histological variety of endometritis which does
not deserve the dignity of being placed in a separate class, and yet
should be mentioned, and that is post-abortum endometritis. Ac-
cording to Schroder 21 it is almost always an interstitial form of metri-




lISp




Fig. 104. — Endometritis Post Abortum, showing Islands of Decidua about which is an Active

Proliferation of Cells.



tis which occurs after abortion, the glands taking part only very late
in the disease. But the feature which distinguishes such metritis ana-
tomically is the persistence of the decidua (vera or serotina) which
undergoes a partial retrograde metamorphosis ; if this persistence is
partial, we find little islands of decidua, more or less prominent,
about which there is a very active proliferation of small cells (Fig.
104). This inflammatory modification of the mucous membrane, adds
Schroder, differs essentially from retention of the placenta, which is
often described under the inappropriate name of endometritis post
abortum, and which is only a hemorrhage post abortum due to incom-
plete contraction of the uterus and its vessels.

Lesions of tlie Cervix.— Anatomically it is incorrect to speak of
metritis of the body as distinct from metritis of the cervix, for these



148



CLINICAL AND OPERATIVE GYNAECOLOGY.



two portions of the uterus are never completely independent ; most
frequently the lesions are synchronous and undergo a parallel evolu-
tion. However, there is often a more decided localization of the dis-
ease in one or the other of these different parts ; and as the cervix is
the more exposed to traumatism, cervical metritis predominates. If
the mucous membrane of the cervix is thoroughly diseased, the pro-
cess is carried step by step into the fibrous and muscular portions, and
thus a veritable parenchymatous metritis occurs with every inflam-




?■ '-W mJ$W)\MMsmg%



Fig. 105.— a, 6, Simple papillary erosion ; c, follicular. Slightly enlarged.



mation of the cervix if of long duration. Cornil expressly describes
a parenchymatous metritis which may be partial. For example, the
lesions are at times restricted to the cervix in the ectropion of the
part caused both by thickening of the mucous membrane, turned
outward into the vagina, and by thickening of the connective tissue
beneath the mucous membrane and between the muscular fibres. In
this connective tissue lesions of recent inflammation can often be
demonstrated, by thickness of the trabecular and of the interposed flat
cells. 22

The neck of the uterus may present special and very diverse lesions



THE PATHOLOGY AISLD ETIOLOGY OF METRITIS.



149



in metritis ; there may be lacerations, ectropion, hypertrophy, conges-
tion, varix, granulations, folliculitis, erosions, ulcerations, cysts, and
ovules of Naboth, etc., etc. When this part of the uterus is accessible




x m3



to the view, the macroscopic description should enter into the clinical
demonstration ; but it is necessary also to make the exact nature of
the disease clear by the resources of histology.

Ovules of JVabotJi, Granulations, Folliculitis. — The ISTabothian



150



CLINICAL AND OPERATIVE GYNAECOLOGY.



glands, so called, are small cysts; granulations and folliculitis are
small ulcerations (I will explain the value of the word farther on),
scattered over the surface of the uterine neck. The one or the other
of these resemble an eruption, and authors have been led to identify
them with those of the external integument, erythema, eczema,
herpes, acne, pemphigus, 23 etc., but the parallel is purely arbitrary,
built upon theoretical views and lacking all serious foundation.

Erosions, Ulcerations. — The cervix may present, near the external
os, a red and rough aspect without protuberances or depressions ; this
is erosion, properly so termed. It may be observed in acute vaginitis




Fig. 107.— Section of the Mucous Membrane of the Vaginal Portion in a Case of Chronic In-
flammation (Cornil). X 40 diara. e, Papillae covered with a single layer of cylindrical epithelium; c,
epithelium begins to be squamous; d, thickening of the squamous epithelium; s, superficial corneous layer;
to, mucous membrane much thickened; p, papillae; t, t, connective tissue; v, vessels



with abundant secretion, or after contact with a foreign body (pes-
saries) ; under the microscope it is seen that there is a simple substi-
tution of flat normal vaginal epithelium for the proper cylindrical.
Fischel 24 has shown that there is often, in the infant at birth, a pseudo-
erosion of the external os, the epithelium being then cylindrical over
a certain zone externally. Later on, this epithelium is invested by
stratified pavement cells ; but when these desquamate, the original
appearance is restored. Should there thus be a congenital predis-
position to erosions it would be a curious fact. The observations of
Klotz 25 seem to favor this view. According to him there are patients
who suffer from erosion or ulceration under the influence of the



THE PATHOLOGY AND ETIOLOGY OE METRITIS.



151



lightest inflammation, wliile others, though there be a severe cervical
catarrh, never present such changes.

This author, moreover, insists on the anatomical differences of the
individual as regards the adult and the virginal conditions of the
cervix and the line of demarcation between the two kinds of epithe-
lium. It would seem, then, that certain women are especially exposed,
by a congenital idiosyncrasy, to cervical metritis.

Ulceration [erosion] is a term applied to still another kind of ap-
pearance : namely, where the entire circumference of the os, or only a
part of it, seems to be depressed over a circumscribed area, presenting
a circular edge and a smooth, red surface or one covered with villi.
Gynaecologists have always regarded this condition as an actual




Fig. 108. — A Portion op the Mucous Membrane of the Previous Figure more Highly Magnified
(Cornil). X 200diam. a, Thickness of the superficial epithelial layer, formed of cylindrical cells much
elongated; e, interpapillary depression; t, connective tissue.



loss of substance with destruction of the tissue, giving it the name
of ulceration of the cervix, and some of them singularly mag-
nify its importance. Lisfranc made this the capital symptom of
his "uterine engorgement;" for him, it was the principal disease.
Then followed a reaction, and Gosselin 26 had the courage — great for
the period when he formulated the opinion — to assert that ulceration
was not at all a disease, but merely the symptom of the uterine catarrh
which Melier's 27 work had made known to the profession. It is not as
an inflammatory lesion, he declared, which reacts upon the system
(Recamier's and Lisfranc's opinion), that ulceration is serious in its
effects, but solely by the enfeebling drain of the discharge.

Tyler Smith, 28 and more recently Roser, 29 see in this lesion only a
kind of hernia of the mucous membrane within the cervix, which is



152



CLINICAL AND OPERATIVE GYNAECOLOGY.



comparable, according to Roser, with the similar condition observed
in the lids during conjunctivitis. This anthor distinguishes a trau-
matic or cicatricial ectropion, due to laceration of the cervix, and an
inflammatory, due to hernia of the mucous membrane. Assuredly a
certain portion of the intra-cervical mucous membrane does make
such a descent when it is swollen so that it passes out of the external
os and appears upon the external surface of the part. It would thus
form the greater portion of the exposed ulcerated surface in deep
laceration. But in the majority of cases the external os is closed and
does not allow more than a very thin edge of the internal mucous




Fig. 109.— Follicular Hypertrophy of the Cervix, a, Anterior lip, internal surface displayed by
an incision; fc, same, anterior lip, front view.

membrane to protrude, and when the ulceration has invaded a large
part of the convexity of the cervix we absolutely must recognize that
the ulceration has taken place in situ, upon that particular surface.

What is the exact nature of the alteration ? Does the ancient
notion of ulceration correspond exactly to an anatomical reality or
only to an appearance ? The authoritative work of Ruge and Veit,
verified in France by De Sinety, clears up this question. These authors
affirm that there is no destruction of tissue, but a new formation;
that while the cylindrical epithelium replaces, at the level of the ex-
ternal ulcerated surface, the pavement epithelium, it is the product of
the adjacent glands, and the interglandular substance between the
depressions assumes the appearance of stakes in a palisade, whence
the papillary aspect of the surface. So that when a bilateral lacera-



THE PATHOLOGY AND ETIOLOGY OF METRITIS.



153



tion permits, by this new glandular formation, a large display exter-
nally, the mucosa projects like a lining of crimson velvet in a sleeve.
It is certain that laceration forms ulceration, but it is exaggeration
to say, with Bouilly, 30 that there is no true ulceration without lacera-
tion due to child-birth. At other times the glands become cystic
and form little projections on the bottom of the ulcerated [eroded]
surface, which thus has the so-called follicular appearance (more
evident in section than to direct inspection 31 ) (Fig. 105, c). These
cysts may form a semi-detached mass on the surface of the part, as
mucous polypi (Fig. 110). They are small, of a red color, semi-trans-




Fig. 110.— Mucous Polypi from the Interior of the Cervix, and upon the Surface, from
Follicular Hypertrophy



parent or purplish, hanging by pedicles more or less free in the cav-
ity, and projecting from the external os; in general resembling the
mucous polypi of the nose, only far more vascular. (It is a mistake
to describe mucous polypi of the uterus in a separate chapter, since
pathologically, clinically, and therapeutically, they belong to hem-
orrhagic metritis. 32 ) When this cystic transformation of the glands
takes place throughout the cervix, it can produce, by penetrating
and dilating its substance, an elongation by follicular hypertrophy
(Fig. 109, a). Finally, the glandular vegetation and the cystic for-
mation may produce within the cavity of a partly-opened cervix small
vesicular projections whijh I compare to an almond (Fig. 109, b). The



154



CLINICAL AND OPERATIVE GYNAECOLOGY.



theory of Huge and Veit, true in most of these cases, is not, how-
ever, so absolute as its authors have declared. Fischel has objected
to their exclusiveness and shown that there is at times an actual
loss of substance, an ulceration in the proper sense of the word.

The epithelium in such cases is desquamated, and the mucous
membrane is renewed by inflammatory granulations which start from
the papilla?. Doderlein 33 has verified the reality of these two pro-
cesses, that of pseudo-ulceration (Huge and Veit), and that of the real
form (Fischel).




!*£ »&r>=i*a<S'.->^s-S



Fig. 111. — Section of a Glandular Uterine Polypus (Cornil). X 60diam. a, a, Superficial nodules
covered with cylindrical epithelium; b, mouth of glands opening into depression between; g, deeper por-
tions of the same glands; v, v, blood-vessels.

Laceration of the cervix is an accident of common occurrence
after parturition. It has been observed after abortion at the second
month, when the elasticity of the foetus would seem to make it un-
likely on a-priori grounds ; but that the cervix should be lacerated,
it is enough that it should be insufficiently softened and dilated. It
is almost always at the first delivery, according to Munde's statis-
tics, that cervical tears occur; though it is possible that both cervix
and perineum, left intact by former child-births, should ultimately
tear. There may not be the least notch in the cervix of a woman
who has had children, and yet a considerable laceration may occur.



THE PATHOLOGY AND ETIOLOGY OF METRITIS. 155

The pathological importance of cervical laceration has been brought
into relief, and certainly exaggerated, by Emmet, who goes so far
as to say : " The half of all nterine affections in women who have
had children depend upon laceration of the cervix."

Pallen estimates the proportionate frequency of the accident as
40 per 100; while according to Goodell it is 1 in 6. Munde, in 2,500
women which had been delivered, found 612 lacerations [25%), but
only 280 (50#) were sufficiently deep to have any pathological impor-
tance; the others cicatrized or gave rise to but little complaint, The
degrees and varieties of laceration are very variable; we can distin-
guish unilateral, bilateral, anterior, posterior, and stellate lacerations.
The bilateral form is the most frequent; then comes the unilateral,
then the stellate, the multiple, the posterior, and, finally, at the end of
the series, the anterior. The unilateral has been most often observed
on the left side; due without doubt to the frequence of the left ante-
rior occipito-iliac presentation, the tear being made by the occiput.



Online LibraryS. (Samuel Jean) PozziTreatise on gynæcology : medical and surgical → online text (page 14 of 53)