Circulatory Disturbances

Active hyperemia is normally present during menstruation and pregnancy, and is similar to what takes place in pathologic conditions. The mucous membrane becomes much congested and swollen and there is a round-cell infiltration between the glands, which are somewhat increased in length. There is probably little or no desquamation of the surface epithelium. Serum is secreted and this may be hemorrhagic or purulent according to the diapedesis of erythrocytes or the emigration of leukocytes.

Passive hyperemia may be part of a general stasis, but is especially marked in severe malpositions or when neoplasms press upon the venous plexuses. The uterus is enlarged, dilated veins are seen on the outer surface, the mucosa is dark red, and the condition generally terminates in a chronic hyperplastic endometritis.

Hemorrhage may be normal, as in menstruation, or pathologic. The blood may be within the uterine cavity, in the uterine walls, or outside in the peritoneal cavity. When the menstrual period is lengthened and more blood than is normal is lost, it is known as Menorrhagia; if the hemorrhage is between the menstrual periods, metrorrhagia. Normally the mucous membrane remains intact, but under certain pathologic conditions large masses of endometrium may be discharged; this is called dysmenorrhea membranacea.

In hemorrhage into the peritoneum the blood usually collects in Douglas's pouch. It may be derived from a ruptured tubal pregnancy, a hematosalpinx, or ruptured varicose veins of the broad ligament. The resulting hematoma may be large or small, and it may become absorbed or be encapsulated. Inflammation may occur with the formation of adhesions between the uterus and rectum. Occasionally the blood may escape by perforations into the rectum or vagina. Death may follow the loss of blood.

Atrophy occurs normally in old age, or as a consequence of the removal of the ovaries. The uterus becomes much smaller, dense, and pale, and the blood-vessels show an ob-literative arteritis. The endometrium is also greatly reduced in thickness and the greater part of the glands is lost.

Following childbirth the uterus under normal conditions at first rapidly atrophies, then decreases more slowly. By the end of the fourth month it has usually regained its normal size. This process of involution consists essentially in a fatty atrophy of the muscular fibers, which decrease not only in size but also in number.

Hypertrophy may involve the entire uterus, as in the enlargement in pregnancy or in chronic congestion and inflammation. Local hypertrophy generally involves the cervix, which becomes much elongated and may present itself at the vulvar orifice.

Fatty degeneration other than the above is unusual, but has been found in typhoid fever, cholera, and in phosphorous poisoning.

Amyloid degeneration is rare; either the arteries or the muscle may be alone involved.

Inflammation of the uterus, if of the outer serous surface, is a perimetritis; of the muscular coat, metritis; of the lining mucous membrane, endometritis.

Perimetritis may result from puerperal infection, or be a part of a general or local peritonitis. In the acute form there may be a layer of pseudomembrane over the uterus and even involving neighboring structures. The process soon becomes chronic with the formation of adhesions. Parametritis is an inflammation of all the structures of the uterus accompanied by a cellulitis of the broad ligament and pelvic tissues. Usually occurs as a result of puerperal infection.

Metritis may be acute or chronic. The acute form generally occurs during the puerperium, but may be the result of gonorrheal infection. The uterus is much enlarged, congested, soft, and infiltrated with leukocytes. Occasionally small abscesses may form. The muscle fibers degenerate, thrombosis of the uterine sinuses and veins is quite common, and gangrene sometimes occurs.

Chronic metritis usually follows the acute form, or is the result of delayed involution of the uterus. There is a round-cell infiltration along the blood-vessels, the connective tissue increases and by contraction causes the muscle-fibers to atrophy. The uterus finally becomes small, pale, and dense. The entire organ is commonly involved, but occasionally the cervical portion is alone affected - it becomes enlarged, congested, and soft at first but afterward indurated.

Acute endometritis is usually the result of infection by pyogenic organisms or by the gonococcus. It may be found in the course of certain infectious diseases, as typhoid fever, cholera, scarlet fever, and diphtheria. The mucous membrane is very hyperemic and swollen, and there is quite extensive desquamation of the epithelial cells. Small hemorrhagic areas are seen, and there is a marked mucopurulent exudate. There are round-cell infiltration and necrosis of the epithelium; the formation of a pseudomembrane may occur. In gonorrhea the cervical portion is the usual seat, in other infections the fundus.

Chronic endometritis may follow the acute variety, or result from general debility, local congestion and malnutrition, or from the irritation of tumors.

The mucous membrane is swollen, there is some round-cell infiltration and a more or less marked mucopurulent secretion. As the condition persists there is an increase in either the interstitial tissue or the uterine glands. In endometritis glandularis the increase in the size and number of the glands is the striking feature. The glandular hyperplasia may be so great as to closely resemble an adenoma. It is difficult to determine from the microscopical examination whether the lesion is a hyperplasia or chronic inflammation, or merely a phase of the menstrual changes of the endometrium. In endometritis interstitialis the glands are much fewer than normal, and there is a round-cell infiltration and hyperplasia of the inter-glandular connective tissue.

Fig. 177. - Chronic Glandular Endometritis. X 40 (Dürck). Uterine glands greatly proliferated, lengthened, and convoluted.

Atrophy may occur in late stages of chronic endometritis and the glands be displaced by connective tissue. In this process the openings of the acini, particularly of the Nabothian glands of the cervix, may become obstructed and give rise to small retention cysts.

Chronic endometritis may give rise to chronic metritis or by extension involve the tubes.

Ulceration or erosion of the cervix is very common, and results from endometritis and from lacerations. There is a destruction of the superficial epithelium with exposure of the deeper tissues. Occasionally there may be a rapid phagedenic ulceration with great destruction of tissue extending to the bladder and even to the rectum. Has been thought to be carcinomatous, but microscopic examinations have been negative.

Lacerations of the cervix result from childbirth; they may be simple, double, and multiple or stellate. They are very slow in healing and the exposed surfaces become covered by granulations. Fibrous connective tissue is usually formed, and the part may become very dense and hard.

Tuberculosis of the uterus is nearly always secondary to that of the tubes. The endometrium is usually affected and presents either a nodular or a diffuse infiltration. At times the endometrium may be completely transformed into a caseous mass.

Syphilis of the uterus is rare, but may occur as a chancre upon the cervix or as gummata.