During this process the loss of blood was great, but ceased as soon as the uterus was freed of the fungosities. These collected in a bason of carbolized water as they were brought away with the curette, were found to almost fill a two oz. bottle. The entire internal surface of the uterus was affected. Some of these fungous matters as brought away with the curette measured six m. m. in thickness. After the curetting, the uterus was well mopped out with tr. iodine, a pledget of cotton moistened with glycerine was placed against the cervix, a dose of morphine administered, hot flats placed to the feet, and the patient left to rest. There was considerable soreness following the operation, and a profuse bad smelling sanious discharge lasting some days, nothing worse. The patient sat up in ten days, and left the hospital January 12, just twenty-nine days after the curetting. Six weeks after leaving hospital she took charge of a house, the family consisting of a gentleman and his invalid mother, doing the entire work except the washing. Shortly after leaving hospital, she menstruated profusely for several days. Since that time, up to the present, she has menstruated every four weeks, lasting from three to four days. Not profuse. CASE II. Mrs. H., German, age 37, enjoyed perfect health until the age of 17, at which time, in consequence of taking a severe cold at the time of menstruation, she had an attack of pelvic inflammation which confined her to the bed for six weeks. She menstruated at 16, menstruation was a little irregular but free from pain and natural in quantity. Since the attack of pelvic inflammation, she has not enjoyed good health. Menstruation has been scanty, generally only a show, lasting one or two days, and always attended with severe pain. She has also suffered severely from leucorrhoea. The discharge has usually been intermittent, recurring every two or three weeks (though sometimes she would be free for some months) lasting for five or six days and attended with severe spasmodic pain. The discharge resembled boiled starch. She was married at twenty-three, never pregnant. She came under my care the latter part of Oct. 1885. She had then not menstruated for two years, was greatly debilitated, and suffering severely from Oxaluria. The latter was relieved by suitable treatment. On examination in the interval of a leucorrhoeal attack the vagina was found healthy, the uterus retroverted and somewhat flexed. The cervix, situated under the symphysis pubis, presented a not unnatural appearance. The fundus in the hollow of the sacrum was enlarged and tender to the touch. On attempting to pass the sound there was marked difficulty encountered at the internal os. The sound entered 3 1-2 inches. The cavity of the uterus was dilated and very sensitive. The patient was placed in the knee chest position, the uterus easily replaced, and a Hodge's pessary introduced. Though the uterus was maintained in position there was no relief from the symptoms. On January 3th, 1886, during one of the leucorrhoeal attacks the patient was placed under ether, preparatory to rapid dilatation of the cervical canal. The cervix was then found turgid and very dark in color from congestion; The canal was rapidly dilated with the Ellinger dilator as modified by Goodell, and the uterine cavity curetted. About two drachms of polypoid growths were removed. The uterus was then mopped out with carbolic acid and glycerine. The patient was confined to bed for one week. She suffered no pain or especial soreness. On the first day of Feb., seventeen days after the curetting, she menstruated. The flow was natural in quantity lasting four days and entirely free from pain. Since this time she has menstruated naturally and without pain every four weeks. Since the curetting she has had only a slight leucorrhoea which has been wholly free from pain. HISTORY.-To Recamier belongs the credit of having described Fungous Endometritis, as also of being the first to suggest its treatment with the curette in 1846. At this time the condition of the Endometrium received marked attention in France from such men Nelaton, Nonat, Trousseau and others. Boyer in Paris wrote a thesis on the subject in 1858 and Goldschmith in Strasburg in 1857. It is however only during the last few years that the subject has received the general attention its importance merits. During the last decade, no one perhaps has written to better advantage on the diseases incident to the lining membrane of the uterus and their treatment than Paul L. Munde. ETIOLOGY.-Congestion of the uterus, long maintained seems. the invariable cause of proliferating endometritis. The worst cases, those attended with the most alarming hemorrhage and the greatest increase of tissue growth follow labor or abortion. There has been in these women a bad getting up, many of them have been the victims of rough instrumental delivery or version, inflicting great in jury to the uterine tissue. Others have sustained laceration of cervix either with or without the use of instruments. And still another numerous class have risen from their beds too early, while the uterus was still greatly enlarged, the upright position and exercise tending to fix and maintain this abnormal condition. It is my own opinion that the remarkable changes through which the mucous membrane of the uterus passes during pregnancy and the puerperal period have much to do with this condition of the endometrium. During the first month of pregnancy the mucous membrane increases ten fold in thickness. It forms the external of the foetal membranes and is cast off entirely during labor or abortion. The new mucous membrane commences to form under the old at the beginning of the eighth month, and at the time of labor consists only of a new transparent film of whitish color and soft consistence, and not until the second month after delivery has it gained the normal structure of the uterine mucous membrane. Any injury to the uterus at the time of labor or abortion producing a condition of increased blood supply must profoundly affect this soft, newly forming membrane. These are not the only causes however, as married women who have never borne children generally suffer from some form of proliferating endometritis associated with this condition of the endometrium, will usually be found either hyperplasia of the uterine tissue, a conical cervix induration from old inflammation in one of the broad ligaments partially fixing the uterus, or some misplacement, a version or a flexion. SYMPTOMATOLOGY.-There is one symptom of special significance, and that is hemorrhage. In fungous endometritis the menses are at first more profuse, then irregular and finally nearly or quite constant. In the worst cases the patient cannot turn in bed without bringing on an alarming flooding. In polypoid endometritis the menstrueal flow is generally increased, both as to quantity and duration, recurring perhaps a little sooner, but there is generally regularity to the flow. In some cases the flow is entirely suppressed. The other symptoms are those usually complained of in uterihe disease, pelvic distress, bearing + Engelmann Mucous Membrane of uterus Amer Jour of obstet May 1875. + Longet Traite de Physiologie, Paris 1850, Generation, page 173. down, pain in one or both iliac regions, generally severe backache, a "sensitive spine" from loss of blood, leucorrhoea, headache; etc. MORBID ANATOMY AND HISTOLOGY, In a well marked case of fungous endometritis the entire surface of the uterine mucous membrane is affected. The adventitious tissue as brought away by the curette is in large amounts, and is usually either in the form of pale, long and thin slices, perhaps 1 m. m. in thickness, or in the form of red, soft, thick masses, which sometimes reach six m. m. (1-4 of an inch) in thickness. These two characteristics are found in the same case. In polypoid endometritis the amount of morbid tissue is small. It is in the form of round or oblong polypi from the size of a pin's head to that of a small pea. There is generally a dozen or more of these in a given Associated with these polypi will be found many shreds of soft pulpy tissues which have been brought away by the curette. case. HISTOLOGICALLY. These morbid products of the endometrium are made up of excessive cell growth, blood vessels and inter cellular granular matter. Occasionally the end of a uterine tubule will be found: DIAGNOSIS. This is made largely by exclusion. If we have the above mentioned symptoms, and on examination find the uterus only slightly enlarged, movable, and unconnected with a neoplasm, the woman under 45 we should strongly suspect a fungous or polypoid endometritis, and should, if there are no contra-indications resort to the curette. PROGNOSIS. This is good, though it is sometimes necessary to persevere with treatment for weeks or months. There is an active tendency towards recurrence in a limited number of cases. TREATMENT. If the uterus is freely movable, without special pain, we can immediately resort to treatment for the endometritis. All other conditions the result of acute or recent inflammation in the uterus or pelvic organs should first be relieved. The uterine curette of Thomas leaves little to be desired in the treatment of fungous or polypoid endometritis. The condition is one of adventitious growth,and must be gotten rid of, and can be more easily, effectively and safely by the curette than by any other method. Generally the uterus should be thoroughly dilated before resorting to the curette. There are conditions frequently associated with these forms of endometritis, which are benefitted or cured by dilation. We also have better access to the uterine cavity after dilatation, are able to use a larger curette and use it with better results, and can more effectively mop out the uterine cavity after curetting if thought best. If ether is given rapid dilatation should be performed, otherwise the Laminaria Digitatis (Sea Tangle tents) should be used. They are cheap, easy of introduction and extraction, and are free from the danger of septic poisoning. A small tent should be introduced in the morning, and retained with a pledget of cotton moistened with glycerine; in the evening this tent is removed and one as large as the existing dilatation will permit introduced. The following morning the uterus will be sufficiently dilated to admit of a large sized curette. The patient should now be put in Sim's position, a Sim's speculum introduced and held by an assistant. The vagina having been thoroughly cleansed; a strong tenaculum hooked into the anterior lip will firmly support the uterus which should be thoroughly curetted over its entire internal surface from above downwards. During the procedure the curette should be frequently withdrawn, and the fungositier clinging to the fenestra shaken off in a dish of carbolized water. When the procedure is finished 'tis best to thoroughly mop out the uterine cavity with tr. iodine, this favors contraction and has an alterative,stimulating effect tending to rid the uterus of any morbid tissue that has escaped the curette, or carbolic acid and glycerine, or other suitable remedy may be used. The vagina should again be cleansed, a pledget of cotton moistened with glycerine placed against the cervix, the woman comfortably placed in bed, warm bricks put to the feet, a full dose of opiate given and repeated if necessary. Should you have reason to fear uterine or pelvic inflammation apply over the hypogastric region continued for thirty-six hours following the curetting. This has a very great preventive effect. The patient should be confined to the bed a week or ten days. Copious hot water vaginal injections morning and night will be of advantage. an ice bag |