Address. as have forced themselves on me during the progress of many years of active work as a general practitioner and us a REMARKS ON ADVANCES IN GYNECOLOGY gynecologist. Our method of treatment must bo based on our ideas DURING THE LAST YEAR; SENILE of etiology and pathology, so that the first effort of the . gynecologist should be to discover, so far as possible, cause of CHAIRMAN'S ADDRESS BEFORE THE SECTION ON OBSTET every disease of women, and to endeavor to RICS AND DISEASES OF WOMEN, AT THE FIFTY-FIFTH obtain a correct understanding of the morbid processa« ANNUAL SESSION OF THE AMERICAN MEDICAL existing in any given case, and in all cases. Fortu¬ ASSOCIATION, AT ATLANTIC CITY, for the the activities of N. J., JUNE 7-10, 1904. nately present age, physicians m the past have resulted in the e-tablishment of a well- H. L. DUNNING, M.D. nigh perfect classification of diseases, with a good nomen¬ INDIANAPOLIS. clature and a very clear understanding of the symptoms and course of the various diseases. Our Before beginning my address, I desire to thank the debt of grati¬ tude to our is immeasurable. As observ¬ members of the Section and to express to them my high predecessors ers and classifiers of the of the appreciation of the honor they have conferred on me in facts, physicians past were to those of the electing me chairman of the Section for the year. Mind- fully equal present day. They however, left us to a ful of the on the chairman of this have, for solve many knotty ques¬ obligations resting those to of dis¬ Section, have used my best endeavor to advance the tion, especially relating the causation ease interest ofI the Section, and to assist in the preparation and the morbid processes induced by the same. I do not need to cite instances. You are familiar with them. for this session of a program worthy of the occasion. We have all witnessed.the todiscover the cause if we have succeeded in this endeavor, a share struggles large of cancer, of of the of of of the credit must be accorded to our secretary, Dr. epilepsy, development neoplasms, C. L. Bonifield. His labors have been faithfully and eclampsia, of the growing sterility in the class of edu¬ cated women. And we the efforts performed, with perseverance and cheerful- so, too, have witnessed efficiently to find not cause the ness. I commend his to all future secretaries. only the but pathology of painful example of the in It will be observed on of our program menstruation, perplexing pain the ovarian perusal printed denominated ovarian of the that we have been able to obtain .twelve papers on ob¬ region usually neuralgia, of organs, and the lack of co-ordination of stetric subjects, besides several others which have an in¬ blighting the nervous In each one of these morbid con¬ direct bearing on the same subject. For valuable sug¬ system. to the of the and ditions, or distressing signs of disease, there is a fruitful gestions relating arrangement program field assistance in obstetric papers, I wish to thank for'investigation. obtaining of the sources of our esteemed Dr. C. S. Bacon. Many infection have been found, member, rheir disastrous results and the methods of THE PROGRESS OF GYNECOLOGY. ascertained, prevention and cure are becoming known. In the la¬ It is not my purpose to indulge in extended remarks bors of Jenner, Pasteur, Koch, Lister, Tate and others, on the progress of gyneeology during the last year, as humanity has been greatly blessed. They have not only master minds have already successfully undertaken the been benefactors of the world, but have given our pro¬ task of writing its history. One seeming fact has im¬ fession immortal fame. McDowell's and Sim's names pressed itself on me as I have studied this history. It should be added to the list of benefactors. The achieve¬ is that there has been less published than usual, during ments of all these great men came not by chance but the year, relating to new operative procedures. The by deliberate effort. In like manner shall appear the year seems to me to have been one in which a large findings of the present and future physicians, for we amount of successful surgery has been done, but one in discover that which we seek to find, more perhaps than which the struggle has been to seek out and find the best we at first thought, for our vision enlarges and our indications and methods. There has been also much understanding quickens as we advance. earnest effort to solve some of the difficult questions of I have been incited to give utterance to these thoughts etiology and pathology as they relate to diseases of because of one or two pessimistic papers and a few re¬ women. marks I have listened to during previous meetings of These are right tendencies, and will assuredly appeal this section. So long as the world stands there will be to right-minded persons everywhere. There are still unsolved problems, and a suffering people waiting for many difficult and important questions demanding so¬ their solution. The moral is, let each man find an un¬ lution at our hands, and it seems to the writer not inap¬ solved problem within the scope of his attainments, and propriate to indicate a few of them at this time. Those then set himself deliberately and persistently to the task mentioned may not be the most important, but are such of its solution.

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/30/2015 SISNIlJi ENDOMETHITItí. In the beginning of acute senile endometritis there is The scientific subject 1 have chosen to discuss at this marked intensity of symptoms. The chronic form of a of a former time is "Senile Endometritis," and it is selected because senile endometritis may be prolongation I believe it has not received the attention at the hands endometritis ; in other words, it may be a continuation of of practitioners and authors its importance demands. an endometritis existing before the menopause. An There seems to a mistaken idea that endometri¬ endometritis resulting from gonorrheal infection and prevail until te women before the menopause progressing the tubes and must be extir¬ affecting disappears in of is after that and that should there be by chance a pated consequence purulent disease, very prone period, to after case prolonged beyond the climacteric, it is of little im¬ persist the salpingo-oophoreetomy, even though portance and easily cured. Such is not the invariable the be most thoroughly curetted. rule. It is true endometritis after the menopause is not When the inflammation so persists it is most distress¬ of so occurrence as it is the childbear- ing and retards convalescence. So distressing and per¬ frequent during sistent is I have ing period, yet is not uncommon, as evidenced by the this post-operative endometritis that come to the belief that endometritis fact that out of 464 consecutive private cases of disease gradually where the of the organs recorded in case-book. is pronounced and has existed long previous to the reproductive my is there are histories of 15 cases of senile endometritis operation, it the better practice to remove the uterus when to the Un¬ of sufficient severity to bring the patients to a special¬ also, necessary extirpate appendages. ist for relief. The of the disease are in questionably, chronic senile endometritis in the major¬ complications of instances acute when the main different from those in the ordinary cases of ity is preceded by endometritis it is not a of an endometritis. Its course is more and the sequel anteclimacteric endometritis. protracted, Rétroversion of the uterus sufferings of the patients marked and characteristic, so and suppurating fibroid that the writer believes senile endometritis should be tumors are recognized as predisposing causes of senile endometritis. of treated as standing in a separate class. Prolapsus the uterus, because of. the of the uterus on and of Clinically, we observe two forms of the disease, classi¬ congestion dependent it, because fied according to the intensity and duration of the in¬ the exposed condition of the and os, must be flammation, viz., the acute and the chronic. The acute considered another cause. So may be laceration of the cervix uteri also. In the latter case not form results from primary infection or from an exacer¬ infrequently bation of the chronic form of the inflammation. I have the diseased condition of the mucous membrane and structures of the cervix a observed a number of cases of acute senile endometritis, deeper furnish suitable field due to infection. In these instances the for the rapid development of microbie action. Because gonorrhea! vag¬ of the ina was involved first and later the . In lowered resisting power of the tissues, together with the of these senile tissues to one case in which there was also mixed infection, the proneness degenera¬ inflammation extended beyond the interior of the uterus tive changes, there is no strong barrier against inflam¬ into the tubes and ovaries and to the pelvic peritoneum. matory changes, due to the activity of the pathogenic bacteria. A os and in some Inasmuch as this raises a question which has not been patulous may much discussed heretofore, I have thought it best to in¬ instances afford ready entrance to infectious material introduced into the The sources and nature troduce the history of this case. It is as follows : . of the infections in senile endometritis are those com¬ Case 1.—Mrs. ., aged 54 years. The menopause occurred mon to diseases of this foirr years previously. She was a large, finely developed col¬ inflammatory region. Gonorrhea is not so ored woman who did not appear to be more than 45 years of frequent after the menopause, yet when it does age. She came into my service at the City Hospital, Oct. 15. occur it often runs a virulent course, involving an inflam¬ 1002. She complained of pain in the hypogastric and inguinal mation of varying degrees of intensity, the vagina, regions and had a . She confessed she uterus and bladder, and not seldom the rectum she also._ thought had gonorrhea, which had been contracted six The history of the following case illustrates a frequent weeks, previously. course in such cases : Examination.—There ivas marked and slight fever, pain Case 2.—Mrs. B., aged 52 years, passed the climacteric disturbance to confine the to the »ys'ernie enough patient bed. twelve years previously. She consulted me Feb. 19, A examination showed 1898, giv¬ vaginal only slight , but ing the following history: She is the mother of six children, marked endometritis, a fixed uterus and induration surround¬ and has always enjoyed good healih until two years ago. when the uterus. Dr. W. S. Dodds a ing made bactériologie exam¬ she became ill, complaining of and micturi¬ ination of the and uterine frequent painful vaginal secretions, demonstrating the tion, vaginal discharge and an inflamed and eroded . presence of and gonococci, streptococci staphylococci. Examination.—At the time of my examination there was but was a case of acute lUagnosis.—Here, then, pelvic inflam¬ little swelling of the vulva, but an intense vaginitis and due to and mixed the infective marked mation, gonorrheal infection, endometritis. The patient of very distress material in complained finding lodgment the uterus, and there exciting an ing smarting, burning and of the external 'nflammation that extended to other weeks itching genitals. pelvic tissues. Two A few weeks' treatment of topical applications of solution of alter her admission an examination showed a marked improve¬ nitrate of silver and astringent douches brought marked relief. ment in the and the inflamed so pelvic peritonitis, prolapsed, that, the vaginitis seemed very nearly well, but the en¬ and agglutinated tubes and ovaries could be A few palpated. dometritis persisted. In this case the discharges were puru¬ later it became formed was days apparent that pus had and lent and offensive. A bactériologie examination showed the in the tubes or ovaries. The declined to accumulating patient presence of gonoeocci in the discharge. There were occasional allow us to operate by abdominal section, but finally consented small uterine hemorrhages. to permit us to the abscess in the tube or aspirate right , Operation.—March 10, 1898. A thorough curet'.ement of the with a hypodermic syringe. By this means we drew from the uterus was done with a sharp cureite and the cavity packed abscess several drops of pus, thus demonstrating the statement with iodoform gauze. Two days later the packing was re¬ 1 have made in a former paper,1 that in acute senile endome¬ moved and the was irrigated with an antiseptic tritis "there is a tendency of the inflammation to to the spread solution. The os and cervical canal were patulous, the uterine and the pelvic peritoneum, in resulting cavity dilated, and the walls of the uterus very elastic, so thai some instances in accumulations within the tubes ova¬ pus and we felt the necessity of caution in lest the uterine ries or to ." curetting, leading pelvic wall be punctured or torn. 1. The Journal A. M. A., Nov. 3, 1900. After History.—For a few weeks after the curet'age the pá-

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/30/2015 Fig. 2.— . Cervical epithelium. . Cystic glands. Fig. 3.—Endometrlum. Area showing a thin atrophie C. Muscularis. D. Congested vessel. E. Round-celled in¬ mucosa, gland tubules few and lying parallel to surface. filtration. Bausch & Lomb 1/6 obj. No inflammatory infiltration. Surface epithelium entirely gone. A. Mucosa. . Gland.

Fig. C.—Outline sketch to show relative thickness of thin areas and thicker areas with inflammatory infiltration. Bausch & Lomb 2/3 obj.

Pig. 4.—Senile endometritis. Mucosa. A. Mouth of Flg. 5.— Cross section body wall of senile uterus. A. gland. . Surface epithelium, shows flattened condition, Normal muscle tissue. B. Area of mucoid degeneration, cells are cuboidal or even squamous. Epithelial layer is Involving both connective and muscle tissue. C. Band not continuous ; only a few such islands as shown here of muscle tissue undergoing degeneration. Bausch & can be found; limit of this "island" is seen at C. Lomb 2/3 obj. Bausch & Lomb 1/6 obj.

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/30/2015 Fig. 1.—Case 3. Senile endometritis. A. Denuded epithelium. . Gland. C. Gland containing blood. Ü. Effused blood in endometrinm. E. Musenlaris. F. Vessel (arterio¬ sclerosis). G. Round-celled Infiltration. Bausch & l.omb, Ob. 2/3.

The Journal of the American Meoical Association.—Illustration of article by Dr. L. H. Dunning.

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/30/2015 tient was markedly better, but then the discharge gradually in¬ vations are at variance with those oí some writers. In creased, became offensive and irritating, and slight hemor¬ the few cases in which 1 have found retained pus, blood rhage appeared. The patient declined to have anything further and débris in the uterine cavity the odor of tiiese fluids done for two years, when the suffering became intolerable, and has been offensive. 1 was asked to do another eurettage. I advised a hysterec¬ exceedingly Usually the cervical canal is so that tomy, but it was rejected; so, Jan. 0, 1900, another thorough easily dilatable, a sound may be with ease. The eurettage was done. As in the former instance, this brought large-sized passed puru¬ lent is some¬ relief for a the became discharge usually creamy in consistency, time, when again discharge profuse, of offensive in odor and to all the tissues it touched. times an offensive odor, and more or less irritating irritating to the In January, 1904, the husband of the patient consulted me external genital organs. Pain is a about his wife's case. He said she was well nourished and persistent symptom. The pain is burning able to attend to her household duties, but that she had the in character. Occasionally the patient may describe the same old foul, irritating discharge, and occasional hemor¬ pain as a sore pain, and in rare instances the soreness rhages. I urged the advisability of a hysterectomy, but this of the pelvic organs is the chief cause of complaint. the patient declined, and I lost sight of the case. Many patients complain of backache and languor, and Case 1 illustrates the further extension of the inflam¬ not a few of them are cachectic, the eachexia due to being mation into the uterine and a mild form of sepsis. In the acute cases there are appendages pelvic perito¬ also neum. In this instance, however, there was a mixed in¬ systemic disturbances, such as a low grade of fever fection. Investigations have not extended far enough and general malaise. Ofttimes the symptoms produced the incidental or to justify positive statements regarding the relative by complicating lesions will over¬ of the different bacteria. It is shadow the symptoms produced the endometritis. importance pathogenic This is true by highly probable, however, that the same principles and especially if there be attended by facts apply in senile endometritis that do in ordinary soreness, pain, itching and extreme nervousness, or if anteclimacteric endometritis. there be kraurosis of the vulva and a caruncle of the . Probably cystitis is the most com¬ SYMPTOMS AND COURSE. plication. distressing Senile endometritis is not a self-limited disease. It In a former article1 I gave the results of a micro¬ is prone to for a of time. The acute examination a persist long period scopic of uterus in which the lesion was form after a time gradually merges into the chronic acute senile endometritis. I the histo¬ form. The are alike in both the acute and To-day present symptoms logie findings in two cases of chronic endometritis. The chronic forms, varying only in intensity. first case is as follows : Some time in the course of chronic senile endo¬ Case 3.—Mrs. 63 C, aged years, was referred to me Jan. 27. metritis there is to 1904, Dr. Peacock of likely appear inflammatory changes by Ladoga, Ind. The patient passed the in the mucous of and membrane the vaginal urinary menopause twenty-three years ago. She states that her health also mucous was until four or tracts, and in the membrane of the rectum. good five years ago, when she had an attack which was When these complications arise, the patient suffers pronounced gallstone colic. She recovered from this, when she to much distress on account of offensive discharges, frequent began have falling of the womb. The latter disease was increased until it and painful micturition, and an uncomfortable fullness gradually had become a great source of discomfort to her, and has and painful abou,t the rectum. Vulvitis is been aggravated because of the feeling necessity of her to common, and leads to intense and marked being compelled lift and care for a helpless itching husband. She that a says for about year she has had a nervous symptoms. The most prominent symptom due from creamy discharge the genitals. Last August, five months to senile endometritis is the discharge from the uterus. she had the first ago, bloody discharge. Since that time she has This is or had a discharge purulent, muco-purulent sanguino- bloody discharge almost continuously. This Ofttimes it is of offensive was at times discharge purulent. exceedingly odor, quite profuse. She states that there is at times and in not a few cases the hemorrhage is considerable, a watery discharge, the odor of which is the very offensive. but sanguineous discharge is most frequently mixed Examination.—The uterus was to the second the prolapsed de¬ with purulent material, and more or less of the com¬ gree, vaginal walls partially prolapsed, thickened and red¬ dened. The external posite mixture may be retained in the uterus and be¬ os showed some slight redness, with two oi· three small come exceedingly offensive. In two of my cases I was areas of papillary enlargement. These bleed readily on touch. There did not seem to be entirely unable at first to understand so much of any localized irea why of inflammation or irritation of this material accumulated within the uterus. The os the vaginal walls. The pro¬ lapsed of the was in both cases. On uterus portion vaginal walls showed the usual thicken¬ patulous examination the ing and due to was roughening, prolapsus, and irritation due to the found to be slightly retroverted. The walls of the of friction the patient's clothing. The of the uterus uterus were thin and and a examina¬ depth M'as elastic, histologie 2% inches. Quite a little sanguino-purulent tion showed the muscular walls to be weakened de¬ from the discharge passed by uterus on examination. It had an offensive odor. processes. In these instances we a generative had full Diagnosis.—I made a diagnosis of senile endometritis and of the cause of the in retro- of the and explanation retention, the prolapsus uterus, decided to extirpate the uterus version and in the diminished because of the contractile power of the prolapsus, which had not been relieved, not¬ uterus. a withstanding prolonged and persistent effort by her regular Dr. Ferguson suggests that in cases such as lie and physician. Dr. Ritter inasmuch as the Operation.—The patient was sent to St. Vincent's examined, discharge found and Hospital in the uterus on it was operated on Feb. 3, 1904, in the of the medi opening after the operation was al presence and that it is students, internes, and with the assistance of Drs. J. Q. slight inoffensive, probable that the Davis and C. E. A uterine were in Ferguson. hysterectomy was done by Hie discharges arrested the folds of the method. uterus Clamp The and appendages were handed over vaginal mucous membrane and there came in contact to with Dr. Ferguson for bactériologie and histologie examination. bacteria which induced decomposition and gave His is herewith rise to report appended, together with drawings the offensive odor so pronounced on ex¬ (Figs. 1 and 2, Case from amination. vaginal 3) microscopic sections. Dr. Ferguson reports on this ease as follows: Occasionally the internal os is closed. This, however, Pathologic Report.—"The length of the uterus is 3 a in is not. in inches, my experience frequent, and this mv obser-. HttV more than one-half of which is cervix. The depth of the

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/30/2015 canal is 2% inches and patulous throughout its course. The scraped by the platinum loop. Culture tubes of gelatin, agar anterior and posterior walls of the body are each % of an and blood-serum were inoculated. inch in thickness and very firm and resistant to the knife. A "The uterine cavity is small, the mucosa lining it smooth, a on mucosa is cyst the size of pea is seen the cervical at the in¬ even and glistening. The cervical canal is pervious. There ternal os. The anterior and posterior lips are much thickened. a rather more than normal constriction at the internal os, but os the fundus is The endometrium from the internal to ec- the external os is gaping. There are numerous small colored chymotie and closely studded with minute elevations.' spots, about the size of large pinheads, resembling petechia> Microscopic Report.—"Material obtained from a portion of scattered throughout the corporeal mucosa. shows an almost entire absence the mucosa by gentle scraping Microscopio Report.—"Sections were made from six areas of and a number of of columnar epithelia, the presence of large the mucosa. All present the same picture. The mucous mem¬ squamous epithelia, and a few red blood cells are found. Sec¬ brane varies greatly in thickness. In some places it is thin Exten¬ tions show the surface epithelium changed or absent. and contains very few glands. The glands that remain are of mucosa is that in or sive round-celled infiltration the found, small, usually with a very narrow lumina, and lie more many places extends into the muscularis. Glands are numer¬ less parallel with the surface. There is no inflammatory infil¬ but are not as ous, extend into the muscular layer, tortuous tration. These areas, then, exhibit the normal atrophie changes in endometritis glandularis chronica. The mucosa presents of senility. in some instances filled with blood. numerous cystic spaces, "In other regions the endometrium is of normal or perhap* These are dilated lined by a single laysr of spaces glands, slightly increased thickness, the glands are numerous but ir¬ columnar The capillaries are numerous in some epithelium. regular and tortuous, many having dilated lumina. The stroma of the mucosa, dilated and filled with blood. The mucosa parts of the mucosa in such places is quite dense, especially around is thickened and infiltrated with blood throughout a greater the There is an irregular round-celled infiltration of of its and surface. The blood vessels of the uterine glands. part depth inflammation in these areas. Throughout the whole endometrial wall show marked the thickened walls in some arteriosclerosis, surface the is almost entirely gone. Only a few instances almost closing the lumen. This thickening epithelium entirely patches are seen, most of them lying about the mouths of is confined to the intima. The epithelial cells are very much flattened and are marked increase in ele¬ glands. "The cervix shows the glandular described as cuboidal, or even cells. blood vessels squamous, numerous adenomata, and congested no ments, cyst "There is no evidence of an ulcération of the mucosa, and Arteriosclerosis is marked. Round-celled infil¬ are present. loss of substance by necrosis and sloughing to produce the tration extends for some distance into the muscular layer. 'thin' areas. There has apparently been a simple epithelial the examination the "Altogether, microscopic gives picture degeneration. I can find no evidence of hemorrhage into the of a chronic endometritis in a senile uterus, with the well-marked mucosa or into the nor any pathologic changes in the due to circu¬ glands, a tendency to hemorrhage, hemorrhage being capillaries. The muscularis shows a spread of fibrosis, proba¬ on degenerative latory disturbances, probably dependent bly not more, however, than is normal to the senile organ in the of the blood vessels and chronic in changes walls conges¬ The blood vessels are markedly thickened, the lumen many to of the uterus. tion incident prolapsus cases almost obliterated by the thickened intima. Hyaline the being Bactériologie Report.—"Immediately after the operation degeneration has taken place to a marked degree in these ves¬ uterus was bisected and cultures made from the endometrium sels. the larger bands of connective tissue, ami The in Throughout on blood serum, agar agar and gelatin. result every involving also bands of muscle fibers, are masses of mucoid tis¬ was A similar examination the instance negative. bactériologie sue, evidently a secondary change to fibrosis." was made in Case 4, with a negative result." There is a marked in the macroscopic and me 1904, similarity Case 4.—Mrs. D., aged 61 years, consulted April 4, of these two uteri. The evi¬ on account of of the uterus which had existed 1% microscopic appearances prolapsus are almost identical in both, had been treated etc., dences of inflammation years and by posture, tampons, pessary, be taken as relief. She was a well-nourished and this leads me to believe that they may without more than temporary chronic senile endometritis, and woman. On examination of the heart, lungs and the of many cases of active type is kidneys nothing abnormal was found. She complained of in which an anteclimacteric endometritis prolonged weight and burning pain through the uterus, and stated that and continued as a lesion after the menopause. from which was she had a thin, creamy discharge the uterus, The characteristic inflammatory lesions present axe of odor. She the irritating and at times offensive passed a for the mqsfc divested of. of the thickened mucosa, part menopause eleven years ago, and was not aware pres¬ and round-celled infiltration, or until 1% epithelium, showing ence of any uterine disease displacement years the in both cases being of uterus the marked granular activity, glands ago. The displacement the preceded appearance some instances weeks she for here and there dilated and in cystic. of the discharge several months. Two ago had, showed activity in the first time in eleven years, a sanguineous flow from the The inflammatory process greater of The are lined with uterus four and as abundant as an ordinary men¬ the region the glands. glands lasting days on the sur¬ struation. columnar epithelium, while the epithelium There is a tortuous Examination.—I found the uterus protruding from the vag¬ face of the mucosa is flattened. in one case 1 the ina. There was also prolapsus of the vagina, and the os was course of the glands, and (Fig. C) are filled with blood. The larger than normal, but not eroded. The uterine sound passed lumina of a few of the glands into the cervical and uterine canals 2% inches. round-celled infiltration extends into the muscularis. In readily found Operation.—She was sent to the Deaconess Hospital and this tissue, in Case 4 (Pigs. 5 and 6) was mucoid operated on April 6, 1904. The external os was closed by su of the connective and muscular tissues. method. degeneration tures, and the uterus extirpated by the clamp In both cases there is marked arteriosclerosis, and in examination of the uterus after re¬ walls of some of Pathologic Report.—An one also hyaline degeneration of the moval showed the organ rather larger than the normal senile the arteries. uterus. There was elongation of the cervix. The supravaginal In both cases there was considerable hemorrhage. Id cervical canal was patulous and the uterine cavity easily dis¬ one case 1) there was found effused blood in the tensible. There was no evidence on macroscopic examination (Pig. other or endometrium and in some of the glands. In the of hemorrhage beneath the mucous membrane into the muscularis. case there had been but a single hemorrhage (profuse), was more evidence of degeneration in the The was to Dr. R. H. Ritter for critical ex¬ yet there specimen given blood vessels than in Case 3. It is amination. Dr. Ritter's report was as follows: walls of the prob¬ uterus removed, "The uterine cavity was opened after the surface had been able that had not the been subsequent seared by a sterile knife, and the surface of the mucosa gently hemorrhage would have occurred.

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/30/2015 DIAGNOSIS. the internal os is quite efficient. In the acute cases I The is made the above enum¬ do not beneve the curette should be employed until the diagnosis by symptoms of erated and by the physical signs. The pain and sore¬ intensity the symptoms has passed. 1 have on sev¬ ness in cases are referred to eral occasions after dilating and washing out the cavity, uncomplicated distinctly interior the uterus. As a rule, the upper portion of the vagina made applications to the of the uterus of pure is inelastic and the uterus difficult of palpation. The carbolic acid, and followed this in one to one and one- of the cervix be almost half minutes with an injection into the cavity of com¬ vaginal portion may entirely No obliterated, but the external os can be mercial alcohol. outward symptoms have followed patulous usually this and felt. In such cases it is common to find the vaginal procedure, very marked relief of the soreness and has resulted. I mucous membrane surrounding the os more or less discharge This is, believe, appro¬ eroded in small areas, and the whole circumference of priate treatment for both the acute and chronic cases. the of the infiltrated and inelas¬ Such applications for a few times may be repeated once upper portion vagina a tic. If now in this field is seen the of the week if well borne. When the acute symptoms have opening and os, from which exudes a mucopurulent or passed, dilatation, curettage packing with iodoform patulous have been and sanguinopurulent discharge, we have in all probabili¬ gauze beneficial not infrequently curative. ties to deal with a case of senile endometritis, and if, The advantages gained by the curettage should be fol¬ a sound into the and lowed up by maintaining a patulous condition of the os, further, passes readily uterus, by and it it is determined that there is an absence of neo¬ by making applications to the endometrium of so¬ any of nitrate of and there is the of a smooth mucous lutions silver in strengths of 5 to 10 grains plasm, presence ounce. surface lining a dilated cavity of the uterus, the diag¬ per nosis of senile endometritis be made. Reference to Figure 6, Case 4, together with Dr. Rit- may confidently ter's In other cases, especially if there be prolapsus of the description of the microscopic findings in this case, I afford an not uterus or laceration of the cervix, the cervix may be will, think, explanation of the fact that a to unusually large for a post-climacteric uterus. Cystic infrequently curettage fails effect the cure of endo¬ metritis. In this case the inflamed mucosa degeneration of the cervix may be observed or an angry portions of the were found in islands or erosion which bleeds readily on the slightest touch. Oc¬ patches, while other portions of casionally there will be found slight papillary elevations the mucosa were normal. If a curettage is not sufficiently from the eroded surface. This latter appear¬ thorough to remove the mucosa in every part of the projecting uterine and ance resembles that seen in squamous- cavity cervical canal, that part untouched closely incipient the curette celled epitbelioma of the cervix, and a differential diag¬ by or only partially removed, if inflamed, remain as a from which will nosis can be positively made only by a histologie study may focus, spread the lesion of of the diseased tissues removed for exami¬ after regeneration of the endometrium. portions If nation. Another source of difficulty in diagnosis is an senile vaginitis and vulvitis exist with the endo¬ occasional presence of an adenoma of the cervix. In metritis, these conditions should be, if possible, cured these cases the sanguineous flow is more abundant and before the curettage. the discharge less purulent. Here also a histologie To this end, two or three times a week the vulva and study of portions of the diseased areas must be made vagina may be painted with a solution of silver nitrate. to confirm the diagnosis. This, with the applications twice a day of Lassaris paste The same remarks hold true regarding the diagnosis to the inflamed tissues and the use of astringent and in doubtful eases in which there is a sanguineous dis¬ antiseptic douches, usually bring relief. charge from the interior of the uterus. Here it is wise In those cases dependent on the presence of a neerotic to thoroughly curette the uterus and make search for fibroid tumor, the remnants of the neoplasms should be evidences of malignancy in the scrapings. In all the removed by the curette or other means. The writer has cases of suspected senile endometritis in which I have met with little success in overcoming rétroversion of explored the interior of the uterus with a dull curette, the senile uterus. If this displacement is the cause of and there has been an absence of an\rthing resembling the endometritis, and the ordinary means of cure fail a neoplasm, the case has proved to be non-malignant, in the grave cases, recourse may be had to hysterectomy. in the case of a sloughing submucous fibroid tumor the During the progress of the local treatment attention difficulties of diagnosis with microscopic examina¬ should be given to the general health of the patient. tion are insurmountable. In severe persistent cases I Tonics, alteratives and laxatives may be employed ac¬ think it important to determine the character of the cording to the requirements of the case.2 Skene places infection, as those due to mixed infection will likely much reliance on the local effects of iodoform applied require energetic treatment, while cases dependent on as a powder to the endometrium. gonorrheal infection will often demand hysterectomy. The tendency toward recovery in senile endometritis When the internal os is closed the uterus will be found is not marked ; indeed, the disease is prone to persist distended, so that if a probe be carried through the ob¬ in spite of all treatment. When it does persist and con¬ struction and the opening thus made dilated, there will tributes largely toward the production of the ill health be an escape of a considerable quantity of purulent or of the patient, vaginal hysterectomy may be resorted to -;anguinopurulent bad smelling discharge. if the patient's condition demands and will justify such TREATMENT OF SENILE ENDOMETRITIS. a procedure. At the of acute is In all, I have extirpated the uterus in cases of senile en¬ beginning cases it all important six that be established and the dometritis times—five times by the vaginal route and good drainage complica¬ once the route. In two tions treated. Should there be stenosis of the os by supravaginal cases the endo¬ duly metritis was associated it should be overcome dilatation. with procidentia, which fur¬ by gentle yet thorough nished the chief indication for The steel dilator may be used, but the tissues of the hysterectomy; in one case there was chronic to cervix are so inelastic that forcible dilatation must be sepsis, due absorption from in one case employed with gentleness lest the tissues be lacerated. the uterus; the appendages had been extir- The tent it can slippery-elm when be passed through 2. Medical Gynecology, p. 500.

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/30/2015 pated because of gonorrheal and the endo¬ Within the last few weeks 1 have also seen a woman metritis was distressing and incurable, the patient being who showed a typical blue line on the gums, granular an invalid. In the remaining case the uterus was ex¬ degeneration of the red blood cells, and complained of tirpated under a mistaken diagnosis, as I believed I was marked colic and constipation. dealing with a case of cervical cancer. These were ag¬ She washed the paint-smeared clothes of her husband, gravated cases of senile endometritis with grave compli¬ a house painter. I could not learn that she came in cations, and the results of the hysterectomy were most contact with lead in any other manner. gratifying. BLOOD CHANGES IN LEAD POISONING. In those cases in which there is atresia of thei os and When lead intoxication a resultant , great care must be exercised in produces the typical blue line on the the intestinal effecting an entrance into the uterine cavity and in gums, colic and constipation, the the and we it maintaining a patulous os. A medium-sized, blunt- anemia, palsies encephalopathy, recognize probe may be gently insinuated into the os, readily. pointed There can be it pushed into the cavity, and this followed by one of no question that also produces latent toxic effects which are not as size, and a still one until an of easily recognized. larger larger opening The observations and sufficient caliber has been made to admit the passage of interesting of Moritz,1 White an elm tent. The dilatation of the os should be Wilcox,2 Grawitz/ Homel,4 Schur and Löwe,5 Rosin ample. and and After a few of of the Bibergeil,0 Reitter7 others, of the presence days draining cavity, eurettage of red blood cells or the treatment of the interior of the uterine cavity showing granulations in persons suf¬ with lead are with the carbolic acid and alcohol may be resorted to. fering poisoning important. With few all observers to con¬ When suppuration of the fallopian tubes or ovaries exceptions, agree the in the acute cases, and stancy of the granulation of the cells of the blood in appear hysterectomy salpingo- lead in oöphorectomy is. in my judgment, the proper procedure. poisoning. Many workers lead, who present no other symptoms, show this blood change. The blood of animals fed on lead early exhibits the Original Articles. granules in the blood cells. Most observers look on the granules as of protoplasmic origin and degenerative in character. The granules disappear from the blood when ARTERIOSCLEROSIS DUE TO LEAD.* the ¿ause is removed. FRANK S. BILLINGS, M.D. Some individuals are more susceptible to this so-called CHICAGO. basophilic granulation than others, and workers in lead The subject assigned to me in the symposium was whose place of occupation is less sunny and poorly ven¬ "Arteriosclerosis Due to Metallic Poisons." tilated suffer more than those in better hygienic sur¬ I have had no experience with the effects of other roundings Basophilic granulation is by most observ¬ metals, and, therefore, confine my remarks to the toxic ers considered of value in diagnosis, and the disappear¬ influence of lead. ance of the granules is a good prognostic sign. MODE OF ENTRANCE TO THE SYSTEM. EFFECT OF LEAD ON OTHEK TISSUES. Lead and its are so used compounds commonly by There is abundant experimental and postmortem evi¬ man that it is not to meet with its ef- surprising toxic dence that lead may attack practically all the tissues of fects in the body. This occurs more frequently because the body. with some individuals it gains easy access to the body. Annino* fed leatl to dogs, rabbits, rats and mice, and it into as a contami- Not only may be taken the body found that animals even of the same litter differ much and nation of food drink and doubtless from prolonged in resistance. Lead soon in the urine. Lead it also be appeared medicinal use, but may taken into the ali- was also found in the fetus, which explains the tendency mentary tract from the hands soiled with metallic lead of women who suffer from lead to abort. or it poisoning from lead paints. Doubtless may be absorbed In the different tissues it was noted that the lead through the skin, as frequent cases of poisoning have produced varied effects. occurred from the use of lead hair dyes. In protoplasm, cloudy swelling, fatty degeneration; Cigarmakers sometime roll cigars on tinned plates vacuolization and granular atrophy and hyaline degen¬ which contain lead, and susceptible individuals are poi¬ eration of the nuclei. soned. Diamond cutters who imbed gems in a\± amal¬ In the later stages, connective tissue which can hyperplasia. gam of lead, be molded in the fingere and There was a decided to and endar- the suffer tendency hemorrhage facilitate cutting of the stones, may from lead teritis, even to obliteration. He observed fatty degener¬ poisoning. ation of the muscularis and of the capillary endothelium. There can be no that some individuals are question Coene and D'Ajutolo9 found that lead had a de¬ to lead. first, very susceptible structive action on parenchymatous tissues; second, on There is now in the Cook County Hospital, Chicago, the blood and blood vessels; and, finally, a sclerosing a man who is from lead came suffering intoxication, who action. This effect, they claimed, applied to all organs, in contact with the metal in the following way : Once a but was most pronounced in the he kidney. week, in his bare arms, carried the bars of lead solder, Oeller,10 in an article entitled "Ueber hyaline used to seal the locks of freight cars, to the several cars Gefässdegeneration als Ursache einer Amblyopia Sa- of a train. This brought his skin in contact with lead 1. Deutsche med. Woch., vol. No. for a few minutes onlv once a week. 1901, xxvii, 5, p. 5. 2. Amer. Jour. Med. Sciences, 1901, vol. cxxii, p. 266. 3. Deutsche med. Woch., 1899, No. 36. *Read at the Fifty-fifth Annual Session of the American Med- 4. Deutsch. Arch. of klin. Med., 1900. vol. p. 357. In lxvii, ical Association, the Section on Practice of Medicine, and ap- 5. Zeitschrift f. klin. Med., 1900, vol. xl. proved for publication by the Executive Committee: Drs. J. M. 6. Deutsche med. Woch., 1902. Jan. 16-23. Anders. Frank Jones and W. S. Thayer. 7. Wiener klin. Woch., 1902, Nov. 20. Note.—The other articles in this svmposium. by Prs. Thayer and 8. Ann. di. Chim. e di. Farmacol, 1894, vol. xx, No. 1, p. 59. Brusii Drennen and Dock, were published in The Journal Septem 9. Ziegler's Beitr\l=a"\ge,1898, vol. iii, p. 449. ber 10. 10. Virch. Arch., 1881, vol. lxxxvi, p. 329.

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