CHAPTER XVIII.

Fig. 117.—Interstitial endometritis: microscopic section of endometrium removed by the curette (Beyea).

Fig. 118.—Glandular endometritis: microscopic section of endometrium removed by the curette (Beyea).

Fig. 119.—Polypoid endometritis (Beyea).

In some cases the glandular hypertrophy of the mucous membrane assumes the form of polypoid growths projecting into the uterine cavity (Fig. 119).

In the advanced stages of all the forms of endometritis cicatricial formation takes place. The normal ciliated epithelium of the endometrium is cast off, and is replaced by flat squamous cells. The glands atrophy; the glandular openings become dilated, and ultimately appear as simple depressions on the surface. In time secretion from the glands ceases, and the cavity of the uterus becomes lined with simple connective tissue.

Chronic endometritis is always accompanied to a greater or less extent by inflammation of the muscular coat of the uterus. The pathological changes that take place resemble those occurring in chronic inflammation in similar musculo-fibrous structures in other parts of the body. A section of the uterine wall is much lighter in appearance than normal, and the whitish bundles of connective tissue are seen interlacing with the more vascular muscular fibers.

At first there is an hypertrophy of the uterine wall from infiltration of inflammatory material. In the latest stages organized connective tissue is formed, and there isproduced a sclerotic condition of the uterus, with atrophy of its normal muscular elements.

The hypertrophy of the uterus, however, that accompanies most of the forms of endometritis is not due altogether to the presence of inflammatory deposits. The uterus possesses the peculiar property of enlarging, by a general hypertrophy of its elements, whenever there is present in its cavity any gross pathological condition. We see this in fibroid tumor. And, as a general rule, the enlargement is proportional to the mensurable size of the disease.

The metritis may involve the whole of the uterine body, or it may occur in localized areas. It may affect only the body of the uterus, or the body and the cervix, or, as we have already seen, the cervix alone. When the disease is localized to part of the uterine wall, the induration of the affected area may sometimes be determined by palpation.

Symptoms.—The symptoms of chronic endometritis are often obscured by symptoms that are to be referred to other accompanying conditions. For instance, the endometritis very often accompanies subinvolution of the uterus, laceration of the cervix, uterine displacement, or ovarian and tubal disease. Cases of simple uncomplicated endometritis are the exception.

The menstrual function is usually affected. The period is of longer duration, the loss of blood is greater, and the periods may occur more frequently than normal; in other words, there is present menorrhagia. In this disease bleeding also occasionally occurs between the menstrual periods. Hemorrhage is a symptom that is most prominent in cases of interstitial and fungoid endometritis.

The secretion of the utricular glands is also increased in amount. This symptom is most pronounced in cases of glandular endometritis. The secretion is thin and purulent in character, and is often streaked with blood. It decomposes very readily, and consequently is oftenoffensive and excites the suspicion of malignant disease.

The character of the typical discharge from the body of the uterus is usually obscured by admixture with discharge from the cervical mucous membrane. Cervical catarrh, or inflammation of the cervical mucous membrane, may, and usually does, occur alone, without involvement of the upper endometrium, but chronic corporeal endometritis is usually associated with inflammation of the cervix. If the discharge is observed at the vulva, it will be still further altered by admixture with the vaginal secretion. The discharge from the corporeal endometrium is thinner and more serous than the mucus of the cervical canal, and is more usually purulent and streaked with blood.

The discharge from the endometrium is very often increased very decidedly immediately before and after the menstrual period.

Pain is a general symptom of chronic endometritis. The pain is uterine in character, and is referred to the lower abdomen and the back. There is also very constantly present reflex headache localized on the top of the head or in the occiput.

The pain may be present at all times, but it is usually most marked when the woman is upon her feet and the pelvic congestion is increased. The pain is always greatest immediately before and during the menstrual period.

General physical weakness and debility are often very pronounced, and seem to be out of proportion to the extent of the local disease. This same phenomenon has been spoken of in the consideration of uterine displacements. The weak and aching back, the dragging sensations in the pelvis, the tired legs, may all appear after the woman has been upon her feet but a short time, and utterly incapacitate her for any kind of labor.

Nervousness, neurasthenia, hysteria, and mental depression and melancholia are apt to occur in this disease. Such nervous phenomena are common to all diseases ofthe uterus. The mental depression is often very marked, and is exaggerated before and during each menstrual period.

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.

Examination with the speculum shows the discharge escaping from the external os. If there is also present cervical endometritis, the discharge presents the characteristics of both cervical and corporeal mucus. It is thick and tenacious, puriform, and often streaked with blood. After the cervical canal has been wiped out the characteristic corporeal discharge may appear unmixed with cervical mucus. This discharge is thin, purulent, and may be streaked with blood, or it may be brownish in color from mixture with altered blood.

If the uterus is examined with the uterine sound, it will be found that the internal os is patulous; the fundus is decidedly tender upon gentle pressure with the sound, and even the gentlest use of the sound may be followed by bleeding.

The patulous condition of the cervical canal and the internal os is a constant characteristic of all kinds of gross disease in the cavity of the uterus. The external os is usually patulous when the cervical mucous membrane is diseased. The external os, the cervical canal, and the internal os are open when the corporeal endometrium is diseased.

The only certain method of making the diagnosis is by the use of the sharp uterine curette, and this instrumentshould always be employed whenever there is even the slightest suspicion of the possibility of malignant disease of the endometrium. 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. Strict antisepsis should be observed.

The causes of chronic corporeal endometritis are various. Almost any disease of the body of the uterus or of the cervix may eventually result in this condition; therefore the different causes of chronic endometritis will be better appreciated after a discussion of diseases of the uterus. Laceration of the cervix, subinvolution, flexions and versions, fibroid tumors, etc., all produce, in time, some form of chronic endometritis.

Primary chronic endometritis may result as a later stage of the acute disease, or it may exist from the beginning in the chronic form. This is especially true of endometritis caused by gonorrhea. Here the invasion of the disease is slow and insidious, and in the majority of cases is preceded by no determinable acute stage.

Sometimes endometritis appears in old women. Bleeding from the uterus, purulent discharge, and pain may be present. The condition is due to the atrophic changes of senility occurring in the endometrium—changes that resemble those that take place in the mucous membrane of the vagina and the external genitals. Though such symptoms may be indicative merely of a benign condition, yet, as they are also characteristic of the early stages of malignant disease, they demand immediate thorough examination and careful watching.

Treatment.—As chronic endometritis is usually secondary to some disease of the cervix or body of the uterus,the treatment should be directed toward the cure of this primary condition.

The operation of trachelorrhaphy will cure the subinvolution of the uterus and the resulting endometritis. Forcible dilatation of the cervix, in the case of an old anteflexion, will relieve the inflammation of the endometrium. Correction of a retroversion will likewise relieve the resulting endometritis. Therefore, though in every case the cure may be hastened by treatment applied directly to the endometrium, yet causative or complicating conditions must always also be treated if we wish the cure to be lasting.

Many cases of mild endometritis may be relieved or cured by attention to the general hygiene and habits of the woman and by applications made only to the vaginal aspect of the uterus. The dresses should be worn loose about the waist and supported from the shoulders. Prolonged standing and slow walking should be avoided. Mild purgation with salines should be maintained. Regulated exercise or general massage should be prescribed. In addition, the vaginal douche, iodine applications, and the use of the glycerin tampon, with depletion from puncture of the cervix, should be used, as has already been prescribed for the subinvolution accompanying laceration of the cervix.

If these methods fail after careful trial, direct treatment must be applied to the endometrium.

The present method of treating chronic corporeal endometritis directly is by the uterine curette. Time is wasted by the use of applications to the interior of the uterus, and a great deal of harm has resulted from such applications carelessly made.

The best curette is the Sims sharp curette (Fig. 120). The Martin curette (Fig. 121) is useful to remove the endometrium from the fundus.

The operation had best be performed in the menstrual interval, though it may safely be performed during the menstrual period. An anesthetic should always be administered.The woman should be placed in the dorso-sacral position, with the feet in the supports. The vulva, vagina, vaginal cervix, and buttocks should be thoroughly sterilized.

Fig. 120.—Sims’s sharp curette.

The anterior lip of the cervix should be grasped with a double tenaculum. The cervical canal should be wiped out with a small sponge or with cotton and irrigated with bichloride, if the external os is sufficiently patulous. The cervical canal and the internal os should then be dilated to about one inch. The position of the uterus should have been previously determined by careful bimanual palpation.

Fig. 121.—Martin’s curette.

The Sims curette should be gently introduced to one cornu and then drawn methodically over the whole of the uterine surface, removing the endometrium in parallel strips, the length of each strip being equal to the distance between the internal os and the fundus. The curette may be withdrawn from the uterus and washed in distilled water as each strip is removed, or withdrawal and washing may be done after two or three strips have been removed. The Martin curette should then be introduced to one cornu and scraped over the fundus, as there is usually in this situation a narrow strip of endometrium that is not removed by the Sims curette.

The uterus should then be washed out with warm sterile water or with a 1:4000 bichloride solution. The washing may be done by holding the cervical canal open with the small dilator and introducing the long tubular syringe nozzle, or by some form of reflux tube (Fig. 122).Opportunity must always be afforded for the escape of the irrigating fluid.

Fig. 122.—Irrigation of the uterus.

The operator should always remember the danger of perforating the uterus by the curette. This accident, which has happened in the hands of the best surgeons, occurs usually as the instrument is introduced, not as it is withdrawn. It is much more liable to occur after labor or recent abortion, when the uterine tissues are soft, than in the conditions now under consideration. If perforation should happen, the uterus should be carefully washed out with the bichloride solution, the vagina should be lightly packed with gauze, and the patient returned to bed. A hypodermic injection of ergotin should be administered, and afterward, when the woman recovers from the anesthetic, small repeated doses of fluid extract of ergot should be administered to ensure uterine contraction. If the operation has been performed aseptically, it is probable that no harm will result from the accident. If peritonitis should develop, celiotomy must immediately be performed.

After curetting the uterus some operators are in the habit of packing the uterine cavity with sterile or iodoform gauze. This procedure is liable to obstruct the escape, rather than favor the drainage, of any discharges from the cavity of the uterus. Elevation of temperature and uterine pain are often caused by it; therefore it is best, after the operation of curetting, merely to pack the vagina lightly with sterile gauze, which should be removed in forty-eight hours. Daily douches of a 1:4000bichloride-of-mercury solution should then be administered as long as the woman remains in bed. The vagina should be carefully dried after the douche, as already advised.

Hemorrhage is never profuse during curetting, and usually ceases after the endometrium has been removed and the uterus has been washed out.

In cases of gonorrheal endometritis it is advisable, after the uterus has been douched and the bleeding has ceased, to apply carbolic acid thoroughly over the whole interior of the uterus, because infection may lurk in the distal ends of the utricular glands, which are not removed by the curette.

Fig. 123.—Microscopic section of the normal endometrium, showing the utricular glands extending into the muscular tissue (Beyea).

The length of time during which it is advisable to keep the woman in bed depends upon the extent and nature of the disease for which the curetting has been done. As a general rule, the longer the stay in bed the better it is for the woman. If the uterus is much enlarged or if subinvolution is present, the patient should stay in bed for two weeks. Such rest in the recumbent positiondiminishes the congestion of the pelvic organs and is of great aid in restoring the parts to a normal condition. Careful attention should be paid to the regularity of the bowels. Mild purgation with saline purgatives should be continued during the convalescence. Daily massage, started two or three days after the operation, will facilitate the cure.

All the endometritial structures are never completely removed by the curette. The distal ends of the utricular glands, which penetrate the muscular coat of the uterus (seeFig. 123), remain after thorough and vigorous curetting.

After removing the endometrium with the curette the cavity of the uterus does not become lined with a cicatricial membrane, but a new endometrium is produced. It is probable that the new membrane is developed from the remains of the utricular glands. The new endometrium grows in a very short time. In some cases it has been sufficiently well formed to permit pregnancy five weeks after curetting.

The first menstrual period, and sometimes the second and third, after the operation of curetting may be missed. As a general rule, the menstrual bleeding is much less profuse than before the operation.

The therapeutic object of curetting for endometritis is to replace the diseased endometrium by a new membrane which has grown under conditions of rest and asepsis.

There is a disease which has been called membranous dysmenorrhea or exfoliative endometritis, in which large membranous pieces of the endometrium or a cast of the whole structure is thrown off at the menstrual period (seeFig. 124). The condition is most often found in virgins or sterile women. The membrane may be thrown off at every menstrual period, or at periods separated by intervals of various length.

Fig. 124.—Membrane discharged in membranous dysmenorrhea.

The menstrual period is usually accompanied by intense uterine pain, which may resemble labor-pain, and which persists until the separation of the endometrium. In some cases of this disease menstruation is very irregular.

The diagnosis is made from examination of the characteristic membrane that is discharged. The condition should not be confused with abortion, in which the large irregular decidual cells will be discovered. Some women are very liable to early menstrual miscarriage, and have repeated accidents of this kind, which in some cases have led the physician to believe that the condition of exfoliative endometritis was present.

The local treatment consists of dilatation and curetting of the uterus, which operation it may be necessary to repeat several times. Careful attention should be directed toward re-establishing or maintaining the general health.

This disease, also called post-climacteric endometritis, occurs at any period after the menopause. There is a thin seropurulent discharge from the uterus, often so profuse as to soil the clothing. The quantity of the discharge may be increased with a certain monthly periodicity. The discharge is often streaked with blood, or is brown colored from the presence of altered blood. There may be occasional or even continuous slight hemorrhage from the uterus. The discharge is usually fetid, and may be exceedingly irritating to the vagina and vulva. The objective symptoms often resemble in all respects the symptoms of cancer of the body of the uterus.

There is usually dull pain in the lower part of the abdomen and the back; and if the disease continues for sufficient time, there may appear symptoms indicative of septic absorption—loss of appetite, emaciation, and slight elevation of temperature.

The pathologic changes which take place in the uterus in this disease have not been definitely determined. It seems probable that in some cases the condition may be produced, as in senile vaginitis, by infection of an endometrium the integrity of which had been impaired by the atrophic changes occurring after the menopause. Microscopic examination of portions of the endometrium removed by the curette shows the appearance of long-standing chronic inflammation.

These cases are often mistaken for cancer of the body of the uterus, and the diagnosis should always be immediately made by microscopic examination of the material removed by a thorough curetting of the whole of the uterine cavity.

The treatment of senile endometritis consists of applications to the endometrium of a solution of nitrate of silver, from one-half to one dram to the ounce of water, or of thorough curetting of the endometrium.

Subinvolution of the uterus is a condition that results from imperfect involution of the uterus after labor, abortion, or miscarriage. The muscular and fibrous structures of the uterus, which had become hypertrophied under the influence of pregnancy, fail to undergo properly the retrograde changes of fatty degeneration and absorption which normally occur after the expulsion of the product of conception, and which are essential for the restoration of the uterus to its normal size. The elements of the endometrium and the vascular system of the uterus also remain hypertrophied; consequently the uterus is larger, heavier, more congested than normal.

Similar arrest of involution may occur coincidently in the ligaments of the uterus, which are left larger, longer, and more relaxed than in the normal condition.

The pathological changes that occur in the subinvoluted uterus are similar to those found in chronic endometritis and metritis, which have already been described. In fact, chronic endometritis and metritis accompany subinvolution from the beginning.

There are many causes of subinvolution of the uterus. Too early rising from bed is a most frequent cause. This is especially true after abortion or miscarriage; for many women treat such occurrences as of but little moment, and refuse to stay in bed for more than a few days.

Imperfect evacuation of the uterus after abortion or miscarriage is a common cause. Laceration of the cervix,retrodisplacement of the uterus, and laceration of the perineum are all causes of subinvolution of the uterus.

The symptoms of subinvolution are the same as those already described under Chronic Metritis—backache, headache, bearing-down pain in the pelvis, general physical debility, leucorrhea, and menorrhagia.

Thetreatmentof subinvolution should be directed toward the relief of the primary cause of the condition. Laceration of the perineum or of the cervix, retroversion, or endometritis caused by retention of placental tissue after miscarriage, should receive appropriate treatment.

Subinvolution may often be cured by the douches, iodine applications, and depletion of the cervix spoken of under the treatment of laceration of the cervix, provided the primary cause is removed or corrected.

In any case the cure is always hastened by thorough curetting of the uterus. This operation should always be performed when the woman is etherized for the relief of any other condition, as a laceration of the cervix or of the perineum.

The cure of subinvolution depends a great deal upon the time that has elapsed from the inception of the condition to the institution of treatment. The secondary changes in the endometrium and body of the uterus resulting from chronic congestion and inflammation in time becomes so established that the disease will not yield to any treatment, even though the primary cause of the trouble may be cured.

In obstinate chronic cases of subinvolution of the uterus amputation of the cervix sometimes has a most marked effect, and this operation should always be resorted to whenever the disease has resisted the milder treatment already prescribed. Amputation of the cervix is sometimes followed by a transformation of all the tissues of the uterus similar to that occurring in normal involution after labor, and a striking diminution in the size of the uterine body takes place. The amputation of the cervix should always be accompanied by a thoroughcuretting. Sometimes the change in the body of the uterus is so marked after amputation of the cervix, or even after trachelorrhaphy, that a condition of superinvolution, or uterine atrophy, results.

Superinvolution of the uterus is a disease the reverse of subinvolution. In this condition the uterus, after childbirth or abortion, not only undergoes the normal involution, but continues to atrophy until the length of the uterine cavity may measure but one and a half inches. The atrophy involves the neck as well as the body of the organ, the Fallopian tubes, and sometimes the ovaries.

Superinvolution of the uterus is a rare condition. The cause is difficult to determine. It has been attributed to great loss of blood at confinement, to prolonged lactation, and to pelvic peritonitis occurring during the puerperium.

Amenorrhea is the most marked symptom of superinvolution. Nervous disturbances and hysterical symptoms may also be present.

The diagnosis is easily made from the history of the case and by means of bimanual examination and the use of the sound. Congenital malformation may be excluded from the fact that a pregnancy has occurred, and senile atrophy from a consideration of the age and history of the woman. The treatment should be directed to restoring and maintaining the general health of the woman.

Iron and the remedies useful in other forms of amenorrhea may be of advantage.

Cancer of the body of the uterus is a rare disease in comparison with cancer of the cervix. The older statistics—those of Schroeder—appear to show that the disease begins in the body of the uterus in about 2 per cent. of all cases of cancer of this organ. This percentage, however, is probably too small. Cancer of the body of the uterus is by no means an infrequent disease; it is a disease for which the physician should always be on the watch.

Fig. 125.—Diffuse cancer of the endometrium.]

Cancer of the body of the uterus originates in the epithelial structures of the endometrium. It may first appear on the surface of the endometrium or deeply in the utricular glands.

The gross appearance of the disease varies as does cancer of the cervix or of any other part of the body.

Cancer of the uterus may begin upon the surface of the endometrium as a superficial ulceration, as a uniform swelling of the mucous membrane, as a polypoid or papillary projection, or as a large cauliflower-like mass projecting into the uterine cavity.

When the disease begins in the utricular glands, it may form nodules throughout the body of the uterus. These nodules are of various sizes, from that of a pea to that of a hen’s egg. They grow rapidly. They may be submucous and project into the uterine cavity, or they may project beneath the peritoneal covering, giving the uterus an irregular nodular appearance (Fig. 126).

Fig. 126.—Nodular form of cancer of the body of the uterus.

In the later stages of the disease the whole body of the uterus becomes infiltrated. The endometrium is destroyed. The cancerous masses ulcerate and break down. The peritoneal covering is for a certain time a barrier to the extension of the disease. In many casesthe whole of the body of the uterus may be infiltrated with cancer, and yet the peritoneum will remain intact. The accompanying illustration (Fig. 127) shows this: the infiltration extends to, but does not involve, the peritoneum.

Fig. 127.—Cancer of the body of the uterus: a large single cancerous nodule (c) in the anterior wall has been divided.

Later, however, the peritoneum, the Fallopian tubes, and the ovaries become involved. Intestinal adhesions are formed, and the disease may extend throughout the abdominal cavity. The cervix and the vagina may be attacked by extension from above, though, on the other hand, the disease may progress sufficiently to destroy life, and yet the cervix may remain unaffected.

Metastasis may take place by way of the lymphatics. Extension by metastasis, however, is unusual.

Cancer of the body of the uterus occurs at a somewhat later age than cancer of the cervix. The average age is between fifty and sixty. The disease attacks both the parous and nulliparous woman, the latter perhaps more often than the former.

The causes of cancer of the body of the uterus are unknown. It is probable that the various forms of endometritis, by diminishing the resistance of the endometrium, predispose to the development of cancer. It has been maintained that fibroid tumors of the uterus, as a result of the accompanying alterations in the endometrium, predispose to cancer. Cancer of the endometrium is certainly not infrequently found in uteri containing fibroid tumors.

Fig. 128.—Malignant adenoma of the body of the uterus (Beyea).

Malignant adenomais a disease of the utricular glands which has been classed by some writers as a distinct disease, by others as a form of carcinoma. In it the gland-spaces are much enlarged, irregular, and joined to other gland-spaces. The columnar epithelial cells often fill the whole of the gland-space (Fig. 128) The cells,however, never infiltrate the interstitial tissue, as in cancer. The muscular wall of the uterus appears to be destroyed by atrophy or by fatty degeneration.

The disease is malignant, it extends to the neighboring structures, and it destroys life. It presents, in the later stages, all the gross appearances and phenomena of cancer.

Thesymptomsof cancer of the fundus are hemorrhage, leucorrheal discharge, and pain.

Fig. 129.—Advanced malignant adenoma of the body of the uterus. A fibroid tumor (F) is in the fundus.

In women before the time of the menopause the hemorrhage may appear as a menorrhagia or a metrorrhagia, as an increase of the normal menstrual bleeding, or as a bleeding occurring at some other time than the normal menstrual period. Such irregular bleeding may be caused by any unusual effort.

After the menopause the hemorrhage may appear as areturn of menstruation, occurring with more or less periodicity, and, as in cancer of the cervix, often contemplated with satisfaction by the woman. It may appear as a slight occasional discharge of blood, as a bloody streak in the leucorrheal discharge, as a spot upon the clothing, or as continuous hemorrhage. In the late stages of the disease there is a continuous discharge of blood.

The leucorrheal discharge at first resembles that of a non-malignant endometritis. It often begins as a gradual increase of a leucorrhea which the woman may have had for several years. It may be streaked with blood. In the early stages there is nothing at all characteristic about the discharge; later, however, it usually becomes very offensive, on account of the breaking down of necrotic tissue. It becomes more purulent in character, and brown in color from the presence of blood. In some cases of cancer of the fundus, however, the leucorrheal discharge remains light-colored and practically odorless throughout the whole course of the disease. It is sometimes thin and watery and exceedingly profuse, saturating many napkins during the day.

The pain of cancer of the fundus is not a marked symptom. It may be absent even though the whole body of the uterus be involved by the disease. When the peritoneum is affected, and extension takes place to other pelvic structures, the pain is much more pronounced. In other cases the pain may be present in the early stages, before the disease has extended beyond the endometrium.

The pain may be referred to the region of the uterus, to the back, or sometimes to parts of the pelvis remote from the uterus, as the crest of the ilium.

Bimanual examination shows a patulous external os, cervical canal, and internal os. As has already been said, this patulous condition is characteristic of gross disease of the endometrium.

The body of the uterus is usually somewhat enlarged,tender on pressure between the vaginal finger and the abdominal hand, and, in the late stages of the nodular form of cancer, irregular in outline.

The causes of death in cancer of the fundus uteri are the same as those that have already been considered in cancer of the cervix. Extension to abdominal organs is, however, more frequent in cancer of the fundus.

Diagnosis.—It is of the greatest importance to make an early diagnosis of cancer of the fundus uteri, because, of all parts of the body that may be attacked by malignant disease, the fundus uteri offers the best prospect of cure by operation. In the early stages the disease can easily be completely removed.

Hemorrhage from the uterus is the universal symptom, and should never be disregarded. The various manifestations of hemorrhage in cancer of the fundus should always be borne in mind, and should always prompt a thorough investigation.

Leucorrheal discharge occurring at or after the menopause, in a woman previously free from such discharge, should also excite suspicion.

If a careful examination of the cervix fails to reveal any cause for the hemorrhage or the discharge, the interior of the uterus should be thoroughly examined by the curette.

A patulous cervical canal and internal os are good indications that there is some gross disease of the endometrium. In cancer of the fundus the cervical canal and the internal os are usually sufficiently open to permit thorough curetting without further dilatation.

The Sims sharp curette may be used with safety if ordinary care be observed. If the woman is nervous, an anesthetic should be administered, though in most cases diagnostic curetting gives but little pain and may be performed without ether.

The operator should not be content with the removal of a few strips or portions of the endometrium. He should remember that in the early stages the disease may be confined to a small area, and, unless the whole interiorof the uterus is gone over, this area may be missed by the curette, and only healthy endometrium may be removed for examination. Such thorough curetting is of especial importance in case the tissue removed should at first present no suspicious features upon gross examination. All portions of the endometrium should be saved and preserved as directed in cancer of the cervix.

The tissue should be submitted for examination to a person trained in gynecological pathology. The recognition of the early stages of cancer of the endometrium, and especially of malignant adenoma, requires the training of the expert. If a positive diagnosis cannot be given from the microscopic examination, the case should be carefully watched, and if the symptoms continue, subsequent curetting and microscopic examination should be made.

Thetreatmentof cancer of the fundus is immediate complete hysterectomy, with removal of the tubes and ovaries. Cancer has recurred in an ovary after removal of the uterus. The hysterectomy may be performed by the vaginal, the abdominal, or the combined method.

The ultimate results of hysterectomy for cancer of the body of the uterus are exceedingly good. Statistics show about 75 per cent. of permanent cures. Recurrence may be considered exceptional. In this respect they are in marked contrast to the results after operation for cancer of the cervix.

Sarcoma of the uterus is a very rare disease. There have been but few properly authenticated cases of this disease reported in medical literature. All cases of this disease should be put on record.

There are two varieties of sarcoma of the uterus: diffuse sarcoma of the mucous membrane, and sarcoma of the uterine parenchyma.

Indiffuse sarcoma of the mucous membranethe endometrium is infiltrated by round or spindle cells.Soft projections or tumors, which may be villous, lobulated, or polypoid in shape, are formed upon the mucous membrane.

The polypoid sarcoma may present at the cervix uteri. The disease extends to the muscular coat of the uterus.

Fig. 130.—Diffuse sarcoma of the mucous membrane of the uterus.

In the later stages ulceration and disintegration of tissue occur.

The cervix is not involved by the disease.

Thesymptomsof this form of sarcoma resemble those of cancer of the fundus. There are hemorrhage, discharge, and pain.

The discharge is serous, and is less fetid than in cancer, as ulceration takes place later in the course of the disease.

The cervical canal is patulous, and in the polypoid form the tumor may be felt projecting into the cavity of the uterus or protruding from the external os.

The fundus uteri is enlarged and is tender upon pressure.A positive diagnosis can be made only by microscopic examination of curetted or excised tissue.

Sarcoma of the uterine parenchyma, or fibro-sarcoma, or recurrent fibroid, begins in the muscular coat of the uterus. It appears as nodules of various size, which may be interstitial or confined to the muscular coat, submucous or projecting beneath the mucous membrane, or subperitoneal, projecting beneath the peritoneal coat. On section these nodules are pale in appearance and soft in consistency. They are rarely found in the cervix. The submucous form of nodule may become polypoid, project into the cavity of the uterus, and with comparative frequency produce inversion of the uterus.

The nodules of sarcoma differ from those of benign fibroid tumors in the fact that they have no capsule. They cannot be enucleated, but are intimately connected with the surrounding uterine tissue. Metastatic nodules occur in the vagina, the peritoneum, and in other parts of the body.

In the later stages of the disease the nodules disintegrate and break down.

It is probable that fibro-sarcoma usually, if not always, originates in a benign fibroid tumor. In the early stage of the disease the microscopic appearances of fibroid tumor are present, and the transition from the benign to the malignant growth may be studied.

Symptoms.—The symptoms of this form of sarcoma resemble at first those of fibroid tumor; they are—hemorrhage in the form of menorrhagia; a serous, non-odorous discharge; and a moderate degree of pain.

Later, when ulceration and disintegration take place, the hemorrhage becomes more profuse and continuous. The discharge becomes fetid, and contains broken-down sarcomatous tissue. The pain becomes more severe. The uterus is enlarged, and the nodular outline may be determined by palpation.

Before metastasis has taken place the differential diagnosis between sarcoma and benign fibroid tumor can bemade only by microscopic examination of the discharge or of curetted or excised portions of tissue. The duration of sarcoma of the uterus is about three years.

Sarcoma may occur at almost any age. Hysterectomy has been performed for this disease in a girl of thirteen. Several cases have been reported under twenty years of age. The most usual period is about the time of the menopause, in the decade from forty to fifty.

Thetreatmentof sarcoma of the uterus is immediate complete hysterectomy. If in the early stage a positive diagnosis cannot be made between benign fibroid and sarcoma, the woman should not be exposed to the dangers of waiting, but the uterus should be immediately removed.

Chorio-epitheliomaorsyncytioma malignumis a rare and peculiar malignant growth of the uterus which occurs after pregnancy. It originates at the placental site from the epithelial cells covering the chorionic villi. It occurs during the course or after the termination of a uterine or tubal pregnancy. In typical cases the disease immediately follows labor at term, abortion, or a destroyed extra-uterine pregnancy. It may, however, remain latent for weeks or months.

The tumor may be a nodular or pedunculated outgrowth attached to the uterine wall; a fungoid growth from the endometrium; or an intramural growth covered with endometrium. The tumor varies in size from that of a cherry-stone to a mass several inches in diameter. It is composed of soft fragile spongy tissue, light or dark red in color, infiltrated with blood, and containing circumscribed hemorrhages. Histologically the tumor consists of many types of cells irregularly placed; syncytial tissue, cells derived from Langhans’ layer, and sometimes chorionic connective tissue. There are numerous cavities containing blood and connective tissue.

Metastatic growths have a similar structure. Metastasis takes place through the vascular system and may reach distant organs—the lungs, liver, and spleen.

Symptoms.—There is no characteristic symptom of chorio-epithelioma. The chief symptom is irregular or continuous hemorrhage from the uterus following a labor, an abortion, or an extra-uterine pregnancy. The body of the uterus is enlarged, and the cervical canal dilated as in cancer and sarcoma. A positive diagnosis can be made only by microscopic examination of tissue removed by the curet.

Treatment.—As the disease is exceedingly malignant and of rapid growth, immediate hysterectomy is indicated.

Fibroid tumors originate in the muscular wall of the uterus. They are composed of elements resembling, to a greater or less extent, those that compose the middle uterine wall. They consist of connective tissue and of unstriped muscular tissue in varying proportions. Uterine tumors composed exclusively of muscular fibres—true myomata—very rarely occur.

A number of names, based upon the proportion of the component elements, have been used by writers to designate these tumors. They have been called fibroma, myoma, myo-fibroma, and fibro-myoma. The natural history of all the varieties is about the same, and varies but little with the proportion of the elements. I shall therefore consider them under the general name of fibroid tumors of the uterus.

Fibroid tumors of the uterus are benign, in the sense that they do not, like cancer, infiltrate contiguous structures or infect the general system.

Fibroid tumors are loosely attached to the surrounding uterine wall. They are usually invested by loose cellular tissue, forming a capsule from which they may easily be enucleated. Blood-vessels, usually of small size, connect the tumor with its capsule. Dense adhesion between the tumor and its capsule is the result of inflammatory action. The loose connection of the fibroid tumor with the surrounding structures explains the ease with which these tumors travel and are squeezed out of the uterinewall. It will be remembered that in this respect the fibroid differs from the nodule of cancer and of sarcoma.

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