ENDOMETRITIS OR CATARRHAL INFLAMMATION OF THE WOMB.

Endo means within, and metritis signifies womb and inflammation, and when all are combined, the compound term denotes inflammation of the lining membrane of the womb, which is the affection that I am now to consider.

It would be impossible to find a single person of middle age who has not experienced sometime during life the discomforts of a catarrh or cold of some part of the respiratory passages, whether in the head or bronchial tubes.

The mucous membranes are especially sensitive to noxious influences, and sound a timely note of warning by an acute catarrh, which, if heeded, will in many instances save the person from a dangerous, if not fatal sickness.

The adage, “Prevention is better than cure,” is one of the most truthful sayings in the English language, and, if persons would profit from the admonitions of a “slight cold,” many a fatal pneumonia or bronchitis could be averted.

What is true of the mucous membrane that is common to both sexes is true of that which is peculiar to the female organs alone.

There is no mucous membrane that is more liable to catarrhal inflammations than that lining the uterus. There never was a woman who was not some time in her life afflicted with a transient uterine catarrh. It may have been of so mild a form that the symptoms which it occasioned were hardly noticed, or, perhaps, ascribed to some other ailment.

There are several varieties of endometritis; some of these are based upon the length of time that the affection has lasted, while others owe their classification to the anatomical division of the uterus into body and cervix. Those that relate to the duration of the disease are either acute or chronic.

Acute endometritis is the most common form; it has also been described under the names of acute uterine leucorrhoea, acute uterine catarrh, and acute internal metritis. It usually runs a rapid course, ending in recovery or in the chronic form. It undoubtedly passes unrecognized in many instances, and in this way many cases of painful menstruation or suppressed menstruation are explainable.

It can be said that at each and every menstrual period there is a physiological catarrh, which belongs to the natural process of the menstrual function. During each menstruation there is a hyperÆmia, or congestion of the mucous membrane, so that the turgent blood vessels rupture, and this constitutes the menstrual flow. Before this congestion reaches the point of bursting the capillaries, and about the time that the sanguineous flow ceases, there is an increased and altered mucous secretion of the mucous membrane. If this secretion is prolonged beyond the normal period that constitutes healthy menstruation, or if it continues to be present at any time between the menstrual periods, it constitutes a disease or a catarrh. Now when we consider the close relation that the normal functions of the womb have to those that are abnormal, and that the one may be the stepping-stone to the other, we need not be surprised that endometritis, or catarrh of the womb, is one of the most common affections to which women are liable.

Chronic endometritis is where the disease has lasted for a long time; some authorities consider it a rare affection, but this is a great error. Any disease so frequent as acute endometritis must, in the very nature of inflammatory processes, become chronic, in a large proportion of cases.

Endometritis of the body of the womb, in contra-distinction to a partial inflammation, located and confined to the mucous membrane of the neck or cervix of the womb, forms another or third variety of this affection. This disease has been described under the names of chronic corporeal endometritis, uterine catarrh, uterine leucorrhoea, and internal metritis, and the seat of it is confined to the lining membrane of the cavity of the womb, without complicating the cavity of the cervix; but there is no doubt that when either the one or the other is the seat of a stubborn catarrh, the remaining portion of the uterus must become sooner or later more or less compromised in the diseased process.

Chronic cervical endometritis is where the inflammation affects the membrane of the neck; this has been described under the names of cervical catarrh, cervical leucorrhoea, and endocervicitis. These terms are all derived in composition from the Latin word cervix, neck.

The uterus is really divided into two cavities that run into each other; one of these is the cavity of the body, while the other is the cavity of the cervix, a fusiform canal, measuring about one inch and a quarter in length. The cervix partly projects into the vagina, and, as a result, is liable to injury and irritation, to which the other portion of the organ is not exposed. Friction and other influences aggravate the inflammatory process, so that erosions, granular and cystic degenerations, follicular ulcers and chronic enlargements, become complications of the catarrhal inflammation of the cervix.

To return again to a consideration of the general aspect of catarrh of the womb, for it is one and the same pathological process that underlies the different forms. There is a simplicity in the relation of cause and effect, that will strike the casual student as one of the most instructive lessons that it is possible to learn, because it also suggests the simplicity of the measures of which persons can avail themselves for the prevention or cure of this affection.

From the physiological reasons that were mentioned as a cause of endometritis, it follows, as a natural consequence, that the predisposition to catarrh of the womb, varies greatly with the age of persons, so that before the age of puberty, at a time when there are no periodical congestions of the womb from the menses, it occurs very rarely, while from the period of pubescence, and during the functional activity of the pelvic organs, it is very prevalent, but at the approach of the menopause and sexual decadence the predisposition is again lost.

As far as the character and nature of uterine catarrh is concerned, that which in technical language is termed the pathological anatomy is no different from what it is in catarrhal inflammations in other organs, so that the remarks that were made on similar affections of other organs, apply with equal correctness to catarrh of the uterus.

There is, however, one exception of which I desire to remind the reader, and that is a hemorrhagic or granular variety of inflammation. In this form of the disease the mucous glands, and the blood vessels that are distributed between these glandular tubules, increase or multiply enormously, so that I have seen the mucous membrane in some places a quarter of an inch in thickness. This is the most obstinate variety to yield to ordinary remedies, and as it occasions excessive and at times dangerous hemorrhage from the womb, it should not be treated as conservatively as the other varieties of which I have spoken.

There is only one sure method of cure that proved in my hands a success, and that consists in the entire removal of the diseased mucous surface.

Dr. DÜvelius of Berlin made the discovery and demonstrated the fact that the mucous glands of the uterus project into the muscular tissue of the organ, and that if the diseased mucous membrane is removed or scraped off, down to the muscular layer, a healthy membrane is regenerated from the terminal glandular ends that remain imbedded in the muscular tissue. This seems to have been proved by experience, for I have performed this operation in several obstinate cases of uterine catarrh, and in several instances the woman became subsequently pregnant, which proves at least that the regenerated mucous membrane is capable of performing its physiological function, as though it never had been interfered with. With proper antiseptic precautions and in skillful hands, there is absolutely no danger in this operation, but the technique should be thoroughly understood by the operator.

The etiology or causation of uterine catarrh resolves itself into predisposing and exciting causes. Predispositions are defined as that constitution or condition of the body which disposes it to the action of disease under the application of an exciting cause. Persons who possess a thoroughly healthy constitution may be exposed to exciting causes without the slightest danger of contracting diseases, to which others who are predisposed fall victims. The predisposing causes of endometritis are a naturally enfeebled constitution; the existence of a scrofulous or tuberculous habit; impoverishment of the blood from chlorosis; prolonged mental depression; improper and insufficient food; prolonged lactation; frequent parturition under unfavorable surroundings; any indiscretion after delivery which interferes with the regeneration of the womb; styles of dress that depress the uterus; want of fresh air and wholesome exercise.

Professor T. G. Thomas, in his work on Diseases of Women, asks the question why most of these influences should produce this affection more than others. His answer is that “they do not do so.” “Sometimes they cause chronic pneumonia; at other times granular lids, and again at other times chronic endometritis.”

The exciting causes laid down by the same eminent authority are “displacement of the womb; excessive or intemperate coition; the use of intra-uterine pessaries; puerperal endometritis; exposure or fatigue after confinement; efforts at production of abortion and prevention of conception; vaginitis either simple or due to gonorrhoeal infection; painful obstructive menstruation; exposure during menstruation; sudden checking of the menstrual flow; and tumors in the uterine cavity or walls.” Some of the causes here enumerated are much more fruitful of the disease than others. A woman whose constitution has been weakened, and whose digestion is deranged, by habits of indolence and luxury, whose style of dress so depresses the abdominal viscera that her uterus is pressed down into the vagina, is particularly liable to develop a catarrhal inflammation from connubial approaches. When these are not without pain, then there is some predisposition that should be inquired into and righted.

Uncleanliness is not spoken of by authorities as among the causes of uterine catarrh, yet it is a very frequent one. I have succeeded in curing so many catarrhal affections of the vagina and uterus by simply advising the use of vaginal irrigations with borated warm water, that I am convinced that a lack of personal cleanliness is a very prolific cause of this affection. The accessible generative organs, both of the female and male, should be the object of thorough rinsings so as to reduce the possibility of infection to the least degree. All mucous membranes have their natural secretions, and these are on light provocations abnormally increased. The vagina is always the seat of more or less bacterial fermentation or decomposition, and if this is retained for any length of time, it becomes not only putrid and offensive, but also a direct source of infection to the mucous membrane of the womb. This is more so in a married woman, who is exposed to the carelessness of her male consort, who has not been apprised of the dangers of septic infection, that may be innocently communicated to the wife by negligence of his own person. The wife is exposed to all and every impurity that the male has on his person, and thus she is in constant danger of having her internal organs infected, from the outer organs of the male.

There is no doubt that many women become infected from this source, and that obscure and stubborn catarrhs of the vagina and womb are strictly traceable to personal uncleanliness of the male. From the researches of Dr. Noeggerath of New York, it would seem that in a great many cases of pelvic diseases in women, the affections can be traced to a latent gonorrhoea in the male. This phrase means a gonorrhoea in the male apparently cured, which even two years after the supposed cure infects a healthy vagina, causing a discharge and a complication of the uterine mucous membrane. I have seen some cases that fully corroborate the views of Noeggerath, so that before we put the blame of uterine disease solely on the shoulders of the wife, let us find out how much the husband is to blame.

Specialists in particular, but doctors in general, often forget that a woman has other organs besides a womb and ovaries; there is a relation of cause and effect between valvular lesions of the heart or diseases of the lungs, that obstruct the return of the venous systemic circulation to the right cavity of the heart, and catarrhal diseases of the pelvic organs.

Biliousness or an affection of the liver, that interferes with the portal circulation, or the pressure of tumors or swellings on the uterine veins, are also among the causes, while the accumulation of feces or habitual constipation is often overlooked as too trivial to deserve professional notice, and yet its removal is often the only successful means to cure the patient.

The various eruptive and infectious diseases, like smallpox, scarlatina, measles or typhoid fever, may excite in their course a uterine catarrh, that will remain behind as a chronic complaint, after the acute affection has subsided.

The acute variety of endometritis is much more prevalent as a disease than is commonly supposed, but, owing to an absence of specific or definite signs, pointing directly to the mucous membrane, which the woman herself can recognize, it is generally mistaken for something else.

The disease begins with signs of an active congestion in the pelvic organs; such as drawing pains in the small of the back and in the groins, and a feeling of fullness and weight at the bottom of the pelvic floor. The urine is voided with pain and there is a sensation of heat in some parts of the urethra. Pressure on the lower abdominal region is painful, and the sensitiveness diminishes from the middle towards one or the other side. In mild cases these symptoms are not accompanied with fever, headache or a disturbance of the nervous system; there may be diarrhoea due to reflex irritation of the rectum, and the stools are accompanied with bearing-down pain. After three or four days there is usually a discharge of a viscid liquid, which in eight or ten days becomes creamy, purulent and often tinged with blood. The fluids that are discharged from the vagina sometimes become so acrid and irritating that, when they come in contact with the skin of the vulva, abdomen or thighs, it becomes irritated and inflamed, which leads to excoriations and an itching, that may spread over the entire body. The reaction of this discharge is either acid or alkaline, depending upon whether the discharge of the uterus or that of the vagina predominates; as the discharge from the uterus is always alkaline and that from the vagina always acid, there is nothing of a practical diagnostic value in ascertaining the chemical reaction of the secretion. The vagina will generally be found to be hot and more or less swollen as in ordinary vaginitis. The womb itself, however, will be enlarged and sensitive, while the cervix is gaping or open. Through the speculum, it is seen to be red and congested, and from the gaping mouth there issues a clear, albuminous-looking fluid or a muco-pus.

In the subacute or chronic form the symptoms are by no means always so prominent as to indicate the existence of the affection, or they are so marked, by some of the numerous complications, which are in the nature of cause or effect, that its recognition will become extremely difficult. The effect which the disease has on the general organism varies greatly in different individuals. Some women of robust appearance have an aggravated form of uterine catarrh without any immediate ill effects on their nutrition or general health. Other women lose flesh early and become weak and worn; they become pale, and the face assumes a yellowish ashen hue with dark rings under the eyes. Through reflex irritation from the nerves of the uterus other nerve centers become involved, so that a general neurasthenia becomes developed with its characteristic concomitants of neuralgia, muscular spasms, uterine colic and hysteria.

With a third class the inflammation spreads from the lining membrane to the substance of the womb itself, causing an enlargement of the uterus, which induces displacements and a dragging sensation in walking, pain in coitus and painful defecation. The inflammation does not limit itself to the womb, but an ichorous discharge creates distressing symptoms of vaginitis, inflammation of the bladder, and pruritus vulvÆ.

When the uterine cavity is the seat of an abnormal vascular activity, there often exist symptoms of pregnancy that may mislead the patient or physician. Nausea and vomiting are sometimes present, the darkening of the skin around the nipples, and an enlargement and sensitiveness of the breasts, meteorism, or a swelling of the abdomen, caused by the accumulation of air in the intestinal canal from reflex nervous irritation, and when this symptom is added to the irregularity of menstruation, it is easy to fall into the error of diagnosing pregnancy.

Sterility on the one hand, and habitual abortion on the other, should direct attention to the probable existence of endometritis. Very often barrenness has led to an investigation of the condition of the uterus which disclosed the existence of the disease. A woman who conceives, and then loses her child in the first months of pregnancy, is afflicted, in all probability, with a chronic endometritis. In these cases, where conception takes place, it is to be presumed that the sensitiveness and irritability of the inflamed mucous membrane is not suitable for the permanent fixation of the ovum, so that the slightest shock will open the flood gates of a congested uterus, and thus the embryo is separated from its attachment, and lost.

The cervix is sometimes the seat of a special feature of uterine catarrh, that is due to the chronic inflammation of the cervical mucous membrane, stimulating a growth or proliferation of its own tissue or structure. This growth causes an enlargement and elongation of the entire cervix, and a spreading of the lining membrane of the cervical canal to the vaginal surface of the cervix. This encroachment of the cervical lining on the vaginal lining is the displacement of the pavement epithelial cells of the vaginal portion by the cylindrical or columnar epithelial cells of the cervical canal, and this gives rise to erosions and follicular ulcers.

These erosions have a glandular arrangement, and are often mistaken for cancerous or malignant growths. There is no doubt in my mind, that most of the so-called successful cures of cancer were nothing but cures of erosions.

The microscopists, whose lively imaginations make them see things that do not exist, would make us believe that they can take a small section of the suspected growth, and establish the existence of cancer by microscopical examination; this is utterly impossible, because the cancer cell is no different from normal cells, and in erosions we often find the follicles so close to each other, and their cells so closely packed, one on the other, that no candid mind can say whether it is a malignant or an innocent growth.

The claim that “nests of epithelium cells,” as the stereotyped phrase goes, constitute scientific evidence of cancer, is utterly absurd. Such eminent authority as Professor Arnold, of Heidelberg, makes the assertion that positive diagnosis of cancer, from a small section or scraping, is impossible. I am myself fully convinced of the truth of this assertion, for while I was making microscopical studies in Germany, I had abundant evidence of the truth of this statement. It is indeed very unfortunate, both for science and suffering humanity, that as yet there is no absolute means of diagnosing cancer positively, and for that reason the quacks, and those who are not quacks, will continue to fleece their victims for supposed cancer.

I believe that the cause of cancer is either due to a ptomaine or organic poison that is generated in the body, or to a specific germ or bacillus. If it be due to the latter, and the germ theory of disease makes that highly probable, there is no doubt that a method of staining will soon be discovered, that will make the specific microbe recognizable in the field of the microscope, but as yet most cancer diagnoses by microscopy are only surmises.

TREATMENT.

Continence in sexual intercourse is one of the prerequisites to the successful treatment of all uterine diseases. This is so often overlooked by those giving advice in such matters, that their otherwise appropriate suggestions for treatment are frustrated. The women who are suffering, appreciate the value of this interdiction without further argument, but the average man does not appear to have the common sense to readily comprehend that the mechanical irritation incident to the sexual act, and the accompanying physiological congestion, will surely aggravate an inflammatory process, no matter of what nature. Men, whose animal instincts dominate their entire being, so that reason, if they ever had any, is dethroned, should stop to consider their immoderate conduct, which perpetuates the suffering of their wives from ailments which men themselves have often inflicted, and for which women are innocent martyrs.

The acute variety of uterine catarrh is to be treated like all other acute inflammatory diseases.

The patient should at once take to bed, so that she may keep herself warm and quiet.

If the inflammation is due to cold or exposure during menstruation, and the menstrual flow has been suddenly checked, then three or four leeches, applied to the inguinal regions on both sides, will be of decided advantage. Over the lower abdominal regions hot compresses should be applied; these are made by wringing cloths or a large folded towel out of hot water, over which a piece of oiled silk, rubber, or oilcloth is laid to retain the heat and moisture. At other times, that is, when the inflammation is not due to cold and a sudden stoppage of the menses, the application of ice bags is preferable to the hot compresses, in the manner elsewhere described.

The pains which are felt in different parts of the pelvis are relieved by using the Femina vaginal capsules; say one every six to eight hours, after a hot vaginal injection of plain water, or a hot sitz-bath. If there is nausea or vomiting that too is often relieved from the soothing influence of the capsule which allays the nervous irritability.

Should the stomach not be in a condition to take nourishment from biliousness or other causes, prescription No. II on page 138 should be taken in tablespoonful doses every four hours until the stomach is settled and the system regulated; if any food is taken it should be between times and of a liquid nature.

If there is straining or diarrhoea, I prefer to employ an enema of one pint of warm German chamomile tea, to which half a teaspoonful of McMunn’s elixir of opium or laudanum is added. If the pain and straining are very severe, one teaspoonful of either is not too much; by requesting the patient to retain the enema for ten or fifteen minutes, the medicine is directly absorbed, and the effect is both soothing and healing. This may be repeated several times a day, if the pain does not subside after the first injection.

The bowels are sometimes found to be in an opposite state, namely, constipated; this must be relieved at once. An enema of warm soapsuds answers the purpose, or a half-tablespoonful of warm water, in which a half-tablespoonful of glycerine is dissolved, makes an excellent injection for constipation.

Hot vaginal irrigations should be at once commenced, and repeated as often as twice or three times a day. I always dissolve a teaspoonful of powdered borax in the hot water, of which no less than half a gallon is used at one time; this is antiseptic and healing. After six or eight days, once a day will be sufficient.

Chronic uterine catarrh or uterine leucorrhoea does not require the active treatment which was recommended for the acute form. It depends quite often on causes, whose removal is absolutely necessary to the intelligent and successful treatment of the affection.

The causes that have been enumerated must be carefully and repeatedly reviewed, so that each individual case can be traced to its source. Those causes that are improbable must be eliminated from those that are probable, so that by a gradual process of exclusion we narrow the number down to those that actually exist. This simplifies the treatment to actual conditions that can be intelligently met.

Vaginal irrigations constitute in the chronic form of the disease an accepted and most useful therapeutic resource. There is nothing that will ever contraindicate a thorough cleansing of the vaginal canal, so that the organ may not be bathed in its own morbid and irritating secretion. It is a wholesome auxiliary to any course of treatment that may be adopted. It avoids self-infection and places the pelvic organs in the best possible condition for the healing powers of nature to work out a cure.

If the uterine catarrh is the result of a venous obstruction due to a congested liver and a general derangement of the digestive apparatus, then any local treatment will be of no avail without first removing the hepatic derangement.

Costiveness or constipation is a very common complaint with women and a very painful cause of womb disease, but it is so simple and ordinary in its nature that the wise will not deign stoop to notice such trifles, but if it required for its removal a surgical operation, for which a handsome fee is the inspiring motive, then we should hear of it as often as we do of lacerations or flexions of the cervix as a cause of uterine catarrh, and its removal would then indeed become absolutely necessary for effecting a permanent cure.

Why is it that the treatment of uterine disease has degenerated into “professional faking” that is alike disgraceful to the profession and a daylight robbery of the patient. A woman, for instance, is suffering from what she supposes to be womb disease. She consults a doctor, or what is still worse, a time-serving specialist, who examines her and sees at once signs of uterine catarrh.

He at once applies a little tincture of iodine or carbolic acid diluted with glycerine or a solution of nitrate of silver to the cervical canal. The woman is now informed that this application must be repeated two or three times a week, for which she must call at the office that number of times every week, for an indefinite period. At each visit she is subjected to the same routine humbuggery for local medication, but does she get any better? In my early professional experience I innocently and ignorantly tried these methods myself, and I say no! But, as a matter of fact, this constant irritation and poking around and into the womb will inflame any healthy uterus, and much more one that is already slightly irritated, so that patients lose their hope and become convinced themselves that they are no better, but feel worse than when they first commenced treatment.

This inefficient treatment, like the examination, is conjectural and mechanical and therefore incomplete and unscientific. The cause of her entire trouble is never approached. The woman suffers for years from constipation, which also inclines her to piles, because the pressure of the hardened feces on the hemorrhoidal veins obstructs the flow of venous blood and the same pressure on the uterine veins congests the mucous membrane of that organ and gives rise to the symptoms of endometritis. All these conditions should be inquired into, and many others, before local treatment is decided on; simply running to the doctor’s office and having these medical applications made to the cervix or canal of the womb amount to nothing; this, as a general rule, does only harm, and is as superfluous as if one were to take a nasal douche of salt water or some other catarrh remedy, whenever he feels a little cold in the head.

The proper course to pursue in this and similar cases is to prescribe an appropriate diet, and regulate the bowels. It is precisely in this way that women who have made the rounds of the doctors, happen to take some patent laxative or nostrum that relieves their constipation, and accomplishes the wonderful cures of which we often hear and that were no doubt Godsends to the sufferers that were cured, after all the first-class doctors failed. By far the greatest proportion of cases of uterine catarrh are of a simple and transient nature and are only intensified by probing and local treatment.

When I first began the practice of medicine, I made the same mistake in following the advice of books and those who should have known better, for they have had ample opportunity to be convinced of the fallacy of these local measures in the great majority of cases, but some minds are incompetent to learn from experience, for that requires close observation, and logical reasoning.

I soon discovered that the catarrhal inflammations got worse, in proportion to the trouble and pains I took to treat them locally, so that I became ashamed of my ill success and abandoned the local treatment entirely, and this I shortly discovered was the means of curing them. Instead, I simply directed patients to rinse themselves with quite warm salt water, that is, a tablespoonful of ordinary cooking salt dissolved in a gallon of water. Now I prefer Femina antiseptic lotion to the same quantity of water, which has greater healing properties than either pulverized borax or common salt. I particularly advised them to keep their feet and lower extremities warm, regulating their diet and keeping their bowels open. I noticed that the patients began to improve, and that the improvement continued until they were fully restored to health and vigor. This method of treatment would not keep an office overcrowded with deluded patients, but it proved far more satisfactory to all concerned than meddlesome measures, and illustrated one of the most common abuses to which suffering women are liable.

In taking a laxative patients must feel their way as to the proper dose to take in their own individual case; constitutions differ very much in this respect, so that it is impossible to lay down one and the same rule for different persons. It is not good practice to give medicines three or four times a day in cases of habitual constipation, for it is liable to derange the digestion and interfere with the appetite. The proper method is one dose at bedtime and this should be increased or diminished until the suitable dose of the remedy has been ascertained; when this is accomplished, the dose of the remedy should be gradually lessened, a few drops every day, till it can be entirely dispensed with. If the ordinary dose fails to relieve the bowels, an additional treatment of glycerine enema at or about the time that the stool is to take place is to be employed. One or two teaspoonfuls of glycerine should be diluted with an equal quantity of water, and by means of a hard rubber piston syringe thrown into the rectum. The stimulating effect of glycerine on the nerves and mucous membrane, materially assists in relieving the torpor of the rectum, which has become insensitive to the irritation of its natural contents.

Patients who are costive must get into regular habits of relieving themselves, that is, have a regular hour every day when to go to stool, then the medicine will in time cure the most obstinate cases of constipation, otherwise it is impossible to cure it. It takes a constant amount of effort to get well, so that those who are too indolent or think it too troublesome to exert themselves, cannot hope to recover.

If there is great debility and impoverishment of the blood, then I would advise prescription No. 1, which are the iron pills, of which three pills should be taken three times a day. The moderate use of wine, either claret or Riesling, with the food, instead of tea or coffee, is very beneficial, between meals a glass of Porter to relieve the gone-in feeling, until the system has recovered sufficient strength to do without it, that is when ordinary exertions are no longer a burden.

The small percentage of cases that do not yield to the above treatment, become legitimate subjects for an honest specialist, for there may be extensive lacerations of the cervix that require surgical treatment, or an elongated cervix that should be amputated, or a granulated hypertrophied membrane of the uterine cavity that should be scraped out; all these operations are without danger if the operator has thoroughly mastered the details of antiseptic surgery and has the manual skill to do the work properly.