cervix are indicated to deplete the uterus. Twelve to twenty leeches
applied to the abdomen above the symphysis will measurably relieve the
congestion of the perimetrium. At a later stage, when the disorder does
not occur at a menstrual epoch, mediate cold-water irrigation, by means
of Leiter's modification of Petitgard's tubes, over the hypogastric
region is an invaluable therapeutic resource. When the affection occurs
during the period, hot compresses applied to the abdomen, hot
sitz-baths, and even hot-water vaginal injections, are grateful.
The rectum and sigmoid flexure frequently require evacuation. A simple
warm- or hot-water enema will usually secure this result. Occasionally
a dose of castor oil is indicated, but drastic cathartics are
distinctly contraindicated.
When the acute metritis is caused by traumatism, as in the case of
operations on the cervix and curetting of the endometrium, the wounded
surfaces demand attention. Under these conditions the neck of the
uterus and the uterine cavity require careful antiseptic local
treatment.
Abscesses in the uterine walls rarely indicate operative interference,
except in case of pointing in the direction of the abdominal cavity.
When incision is indicated the pus-cavity is usually large and
superficial, and its evacuation involves no especial difficulty.
The treatment of the later stages of acute metritis will be considered
in connection with the subject of Chronic Metritis.
Chronic Metritis.
SYNONYMS.--Chronic uterine infarct (Kiwisch); Diffuse connective-tissue
hyperplasia of the entire uterus (Klob, C. Braun, Wedl); Induration of
the uterus (Wenzel); Engorgement (Lisfranc); Hysteritis, Phlegmasie
rouge (Duparcque); Congestion ou engorgement hypertrophique métrite
(Becquerel); Interstitial metritis (De Sinéty); Congestive hypertrophy
(Emmet); Areolar hyperplasia, Diffuse interstitial hypertrophy,
Sclerosis uteri (Thomas, Skene); Subinvolution, Irritable uterus
(Hodge).
In the absence of exact knowledge with reference to the ultimate
pathology of so-called chronic metritis, it is impossible to frame a
definition which cannot be justly criticised. Schroeder's definition
answers all practical purposes, and probably contains as few
objectionable terms as any other in the literature of the subject.
DEFINITION.--Hyperplasia of the connective tissue of the uterus
combined with increased sensibility.
ETIOLOGY.--1. Subinvolution of the puerperal uterus is a frequent cause
of chronic metritis. But the number of etiological factors which {451}
interfere directly and indirectly with the retrograde metamorphosis of
the puerperal uterus is immense. Getting up too early from childbed,
inability to suckle the child, too early sexual intercourse, retention
within the uterine cavity of blood-clots or placental remains, acute
inflammations of the uterus during the puerperium, retroversions and
flexions of the puerperal uterus, severe exertion and the like,--are
some of the more usual causes in this connection. Involution of the
puerperal uterus is effected by contractions of the muscular walls,
fatty metamorphosis of the uterine substance, and profuse secretion.
Disturbance of any one of these processes may defer indefinitely the
return of the organ to its normal relations. When pregnancy is
prematurely interrupted the operation of each of these factors is
materially modified. Uterine contractions are relatively feeble. The
stimulus of a nursing child is also lacking. The albuminoids of the
muscular protoplasm are not so readily converted into fat capable of
easy resorption. A comparatively large quantity of decidua vera--even
in the absence of portions of the foetal envelopes--is retained within
the uterine cavity, and the secretory activity of the endometrium is
seriously disturbed. Then, women are less careful after miscarriages
than labor at term.
Laceration of the cervix uteri--an accident liable to occur in abortion
as well as during confinement at term--if at all extensive, usually
interferes with the retrograde metamorphosis of the uterus.
2. Continuous or repeated hyperæmia, active or passive, frequently
exceeds physiological limits and leads to chronic metritis. Menstrual
subinvolution, dysmenorrhoea from organic stenoses, flexions, changes
in position with retained menstrual fluid, excessive venery,
masturbation, conjugal onanism, chronic endometritis--especially
gonorrhoeal--inflammations of the pelvic cellular tissue, chronic
oöphoritis, new formations as in the case of carcinoma and
myoma,--result in the production of active flexion and venous
engorgement. The pernicious effects of conjugal onanism in the
causation of chronic uterine infarct have been dwelt upon with
particular fondness by Wenzel, Scanzoni, Emmet, Goodell, and numerous
other ancient and modern gynæcologists of distinction. Van de
Warker,[12] on the other hand, is of the decided opinion that the
operation of this etiological factor has been exaggerated. His
conclusions are based upon an incomplete gynæcological study of the
Oneida Community. Onanism was practised on a colossal scale by this
strange people for a number of years. Summing up the results of his
imperfect investigations, Van de Warker says: "I can discover nothing
but negative evidence relating to the effect of male continence upon
the health of the community." It is quite possible that too much
importance has also been attached to excessive venery. Fritsch[13] does
not stand alone when he says, "I have examined puellæ publicæ for
years, but have not gained the impression that metritis chronica is of
frequent occurrence."
[Footnote 12: Ely Van de Warker, "A Gynecological Study of the Oneida
Community," _The American Journal of Obstetrics, etc._, August, 1884.]
[Footnote 13: Heinrich Fritsch, _Die Lageveränderungen und die
Entzündungen der Gebärmutter_, 1885, p. 318.]
3. Venous stasis from organic hepatic, cardiac, and pulmonary diseases
doubtless predisposes to chronic inflammation of the metrium. {452}
Constipation, usually habitual with invalids, and an over-distended
bladder, are causes which are more frequently and directly operative in
the production of vascular engorgement and displacements of the uterus.
4. Various operative procedures upon the cervix, ill-advised and
frequently repeated intra-uterine applications, must be included in the
list of causative agencies.
5. Chronic metritis is one mode of termination of acute inflammation of
the uterine parenchyma. This method of origin, however, is seldom
observed except after repeated attacks of acute inflammation, as in the
case of gonorrhoeal infection.
The enumeration of possible causes might be indefinitely prolonged.
Scanzoni's classical monograph on chronic metritis contains a much
larger number. As remarked by Fritsch,[14] "In the elastic bands of his
conception of the disease every catarrh, every affection of the uterus,
fitted finally snugly into place." The more common efficient causes
have been indicated.
[Footnote 14: _Op. cit._, p. 299.]
PATHOLOGICAL ANATOMY.--Modern pathological doctrines on chronic
metritis are largely modifications of the opinions so ably advocated by
Scanzoni[15] in 1863. Scanzoni, while fully recognizing the various
forms of chronic uterine infarct, simplified the study of the subject
by comprehending them all under two stages: I. the stage of
infiltration; II. the stage of induration.
[Footnote 15: _Die Chronische Metritis_, Wien, 1863.]
I. In the first stage the uterine tissue is infiltrated with serum,
blood, and fibrin (serös-blutige, serös-faserstoffige Infiltration).
The organ is in a state of engorgement oedema, the consequence of
active and passive hyperæmia. It is enlarged in volume, altered in
shape, reddened and more or less sensitive on pressure, soft and doughy
to the sense of touch. The uterus may remain in this condition, or,
after a longer or shorter interval, pass over into the stage of
induration. Long-continued venous hyperæmia leads with comparative
infrequency to induration, although intercurrent inflammations,
exudations, and new formations of tissue may produce that effect. This
stage cannot be invariably viewed as of an inflammatory character.
These enlargements of the uterus are frequently examples of the
nutritive disturbances commonly observed in other organs in consequence
of long-continued venous hyperæmia. The close correspondence of
Scanzoni's stage of infiltration with Emmet's congestive hypertrophy is
at once apparent.
II. In the stage of induration a luxuriant growth of connective tissue
replaces the specific tissue-elements which are destroyed by a chronic
inflammatory process. Early in this stage there may be an actual
increase in size of the individual muscular elements. Ultimately, the
hypertrophy disappears, the soft and succulent connective tissue
becomes fibrillated, and the vessels are narrowed, sometimes
obliterated, by its contraction. The uterus, though still enlarged and
altered in shape, is of a pale color, anæmic, dry, tough, and hard.
Ultimately, the uterus is reduced in size by the cicatricial
contraction of the firm, fibrillar connective tissue. On section the
tissue is white, of cartilaginous consistence, and the knife creaks as
it divides the structures. Scanzoni's stage of induration is thus
nearly identical with the areolar hyperplasia, diffuse interstitial
hypertrophy, sclerosis uteri, of Thomas and Skene.
{453} Klob[16] a pupil of Rokitansky's, attributes the hyperplasia of
connective tissue to nutritive disturbances, considers the terms
chronic metritis and chronic infarct anatomically incorrect, and
classes the condition among the new formations. Carl Braun[17] and Wedl
in 1864 assumed the same position.
[Footnote 16: Jul. M. Klob, _Pathologische Anatomie d. Weibl.
Sexualorgane_, Wien, 1864.]
[Footnote 17: _Lehrbuch d. g. Gynaekologie_, Wien, 1881, p. 351.]
Klebs[18] is of the opinion that, although the so-called chronic
uterine infarct may be of inflammatory origin, in the majority of cases
the clinical and anatomical demonstration is lacking. With Scanzoni and
Virchow, he distinguishes two forms of the disease, the one consisting
in hyperplasia of the muscular elements, the other in a similar change
in the connective tissue.
[Footnote 18: _Handbuch der Pathologischen Anatomie_, Berlin, 1873, iv.
p. 878.]
Birch-Hirschfeld[19] supports the doctrine of Scanzoni, that the stage
of induration at least is of an inflammatory nature. The connective
tissue is formed out of emigrated white blood-corpuscles. Hypertrophy
of the muscular elements is also observed in certain cases.
[Footnote 19: _Pathologische Anatomie_, p. 1131.]
Fritsch[20] has materially strengthened the position of Scanzoni by his
recent anatomical investigations. Mayrhofer[21] substantially
reproduces Scanzoni's doctrines.
[Footnote 20: _Op. cit._, p. 309 _et seq._, Stuttgart, 1885.]
[Footnote 21: _Entwicklungsfehler und Entzündungen des Uterus_.]
Finally, the great majority of modern clinicians have accepted
Scanzoni's teachings as originally uttered or as modified in
non-essential details. Schroeder,[22] De Sinéty,[23] and A. Martin[24]
are notable examples of the truth of this statement.
[Footnote 22: Carl Schroeder, _Handbuch der Krankheiten d. Weibl.
Geschlechtsorgane_, Leipzig, 1881, p. 91.]
[Footnote 23: L. de Sinéty, _Manuel practique de Gynécologie et des
Maladies des Femmes_, Paris, 1879.]
[Footnote 24: _Op. cit._, Wien, 1885, p. 185.]
The hyperplasia of the connective tissue may be diffuse or
circumscribed. It may be limited in development to the collum or corpus
uteri. The perimetrium is usually thickened, and other signs of chronic
inflammation of that structure are usually present. Chronic
endometritis is a constant accompaniment. The pelvic connective tissue
is not commonly involved. The plexus pampiniformes and utero-vaginales
frequently undergo varicose dilatation.
SYMPTOMS.--The onset of the disease is so insidious and protracted that
it is difficult to determine the exact order of occurrence of the
symptoms in point of time. Then the complications are so numerous and
important that the symptoms of the chronic metritis are frequently
masked. A sensation of weight, fulness, or pressure within the pelvis
may direct the patient's attention to her condition. This sensation may
increase to such a degree that the woman complains of heavy, dull,
dragging pains, referred to the centre of the pelvis or the sacral
region. Backache is a constant and distressing symptom. Pains radiating
up over the abdominal parietes and down the thighs are frequently
experienced. Coitus may be productive of acute distress. When the
uterus is anteverted, pressing against the bladder, ischuria is the
usual result. Constipation, usually present as one of the etiological
factors, is aggravated by the retroversion or retroflexion of the
top-heavy uterus. Under these {454} circumstances one or both ovaries
may be drawn down along with the prolapsed, retroverted uterus, and add
materially to the woman's discomfort. The act of defecation is painful;
the woman avoids the water-closet, days and even weeks elapsing between
evacuations.
Disturbances of the menstrual function are constant. All forms of
dysmenorrhoea, including dysmenorrhoea membranacea, are liable to
occur. Menstruation is usually profuse, giving origin to menorrhagia,
which usually results in the production of an alarming degree of
anæmia. The periods are irregular in recurrence and duration. The
periodic discharge of blood may last from one to three weeks, and then
cease, to reappear after a variable interval of from six to eight
weeks. In other cases menstruation may last the usual length of time,
but recur every two or three weeks. Amenorrhoea may be observed in the
stage of induration.
Priestly,[25] Fasbender,[26] Fehling, and numerous other clinicians
have called attention to intermenstrual pain (règles surnuméraires) as
a tolerably constant symptom of chronic metritis. From fourteen to
fifteen days after and before the regular time for menstruation vague
intrapelvic pains are complained of, and the woman is of the opinion
that the monthly flow of blood is about to begin. The pains, however,
are not so severe, and do not last so long, as those of menstruation.
Occasionally bloody mucus may escape from the vagina. Fehling ascribes
this intermenstrual pain to the swelling of the mucous membrane
preparatory to the next monthly discharge of blood. The symptom is not
at all pathognomonic, as it occurs in connection with oöphoritis and
other pathological conditions.
[Footnote 25: _Brit. Med. Journ._, 1872, p. 431.]
[Footnote 26: _Zeitschrift f. Gebürtskulfe und Frauenkrankheiten_, i.
1.]
As the result of the chronic endometritis, which usually follows
parenchymatous inflammation, metrorrhagia is frequently observed.
Leucorrhoea, more or less profuse, is a constant symptom. Opinions vary
extremely as to the systemic reaction following chronic metritis.
General failure of nutrition, functional disturbances of the
gastro-intestinal canal, hysteria, headache,[27] facial neuralgia
(Barnes), coccygodynia, vaginodynia, skin diseases, alopecia (Hebra),
and a host of other affections, have been ascribed from time to time to
the direct influence of chronic uterine infarct. Doubtless, the
condition under discussion plays an important rôle in the production of
these and other disorders. But the position is utterly untenable at the
present day that chronic parenchymatous inflammation of the uterus is
the efficient cause in the absence of all other etiological
factors.[28]
[Footnote 27: Peaselee, "Uterine Headache," _American Medical Monthly_,
1860.]
[Footnote 28: Fritsch, _op. cit._, 1885, p. 323.]
Intercostal neuralgia and mastodynia, with swelling of the breasts and
darkening of the areolæ, are phenomena of such constant occurrence in
connection with chronic uterine infarct that a direct causal nexus is
in a high degree probable. The investigations of Krause[29] have
established the fact of anastomotic communication between the arteries
supplying the mammary gland and those distributed to the uterus. The
perforating branches of the internal mammary artery supply in part the
mammary gland. The superior epigastric artery, one of the terminal
branches of {455} the internal mammary, anastomoses with the inferior
epigastric, which arises from the external iliac a few lines above
Poupart's ligament. The inferior epigastric sends off a spermatic
branch which passes along the round ligament and anastomoses with the
ovarian artery derived from the aorta, and the uterine artery derived
from the anterior trunk of the internal iliac. The nervous
communication is effected through the sympathetic and spinal nerves.
There is nothing remarkable, therefore, in the occurrence of
intercostal neuralgia, mastodynia, and nutritive disturbances in the
mammary gland as the result of chronic parenchymatous inflammation of
the uterus. The intercostal neuralgia and mastodynia are examples of
reflected neuroses the result of compression of nerve-fibres by the
infiltration or of an ascending neuritis (Fritsch).
[Footnote 29: _Specielle und Makroskopische Anatomie_, Hannover, 1879.]
PHYSICAL SIGNS OF CHRONIC METRITIS.--Bimanual palpation prior to the
stage of cicatricial contraction reveals alterations in size, shape,
position, consistence, and sensibility of the uterus. Variations in
size are extreme. Veit[30] has recorded a case in which the fundus
extended two inches above the umbilicus. The uterus is usually
thickened, especially in its antero-posterior diameter. As regards
position, the organ may be prolapsed, elevated, or remain in situ. The
consistence will depend upon the stage of the disease. During the stage
of infiltration the organ is soft and imparts a doughy sensation to the
examining finger. During an exacerbation of acute inflammation the
vagina is hot and dry; the uterus is swollen with blood and very
sensitive on pressure. During the intervals between exacerbations no
change in sensibility is noticed. The sound demonstrates a varying
degree of elongation of the uterine cavity. During the second stage,
after cicatricial contraction of the connective-tissue elements, the
uterus is relatively small, hard, and insensible.
[Footnote 30: _Frauenkrankheiten_, 2 Aufl. p. 367.]
The cervix is hard or soft according to the time of examination. In
virgins or women who have not borne children enlargement is of
relatively infrequent occurrence. In multiparæ, especially in cases of
bilateral cervical laceration, the increase in volume is great. The
mucous membrane of the cervical canal is everted and studded with
minute cysts--distended follicles.
The influence of chronic metritis upon conception is not direct. When
the endometrium is not seriously involved the condition seems to
exercise no untoward influence. However, associated with chronic
uterine infarct as complications we have endometritis, salpingitis,
oöphoritis, perimetritis, and displacements, pathological states which
may obviously cause sterility.
When conception does occur, abortion follows with relative frequency.
The reason why is not clear. The chronic endometritis may interfere
with the development of the decidua; the parenchyma may not be able to
undergo evolution. When pregnancy reaches its normal termination, labor
is not materially influenced by the pathological condition of the
uterus, but complications are liable to occur during the puerperium.
Postpartum hemorrhages which do not readily yield to ergot are observed
as the result of the deficiency in muscular elements. The hyperplasia
of the connective-tissue elements and destruction of the muscular
tissue is a distinct predisposing cause of complete or incomplete
uterine inversion. {456} Subinvolution is increased. Menstruation
recurs soon after pregnancy, and the chronic metritis is
aggravated.[31]
[Footnote 31: A. Martin, _op. cit._, Wien, 1885, p. 189.]
Occasionally, gestation, parturition, the puerperium, and lactation
seem to exercise a favorable influence on the state of the parenchyma.
In exceptional cases all traces of the original chronic metritis
disappear with the puerperium. The connective-tissue hyperplasia may
undergo the same involution to which the hypertrophied muscular tissue
is subject. This favorable termination of the disease is seldom
observed during the stage of induration.
TERMINATIONS.--I. Chronic metritis may terminate during the stage of
infiltration in resolution. This mode of termination is rare. It is
observed occasionally as the result of involution in the puerperal
uterus. Judicious treatment in favorable cases may reduce the size of
the uterus and relieve all distressing symptoms. Recidiva of the
disease are liable to occur, however, and all traces of the former
condition seldom disappear.
II. Usually, the condition persists, with acute exacerbations, through
years, until cessation of menstruation and ovulation occurs. Under the
influence of the change of life the symptoms may gradually disappear
and the uterus may undergo senile atrophy. In some cases chronic
uterine infarct seems to defer the climacteric changes. Finally, the
disease may continue after the menopause, usually with abatement in the
severity of the symptoms.
III. The morbid condition may terminate in induration. The uterus
becomes comparatively small, hard, and insensible. Amenorrhoea may be
the result. This process may be viewed as a relative cure, since it is
attended, as a rule, with amelioration of all the troublesome symptoms.
DIFFERENTIAL DIAGNOSIS.--It is not always an easy matter to institute a
differential diagnosis between chronic metritis and pregnancy and
fibroid tumors by bimanual palpation. Alterations in the volume, form,
position, consistence, and sensibility of the uterus occur in pregnancy
as in chronic metritis. But in pregnancy the uterus, particularly in
its vaginal portion, is softer; the organ is not so sensitive; the
cyanotic hue of the vaginal mucous membrane is more marked; arterial
pulsations in the vagina are more evident; the uterus enlarges more
rapidly; finally, there is the history of the case. Pregnancy may
occur, however, in a chronically inflamed uterus, and this fact must be
borne in mind.
The alterations in the size of the uterus are usually circumscribed in
fibroid tumors. One wall is thickened; the other retains its normal
relations. In submucous fibroids the cervix is shortened; in chronic
metritis it is usually enlarged. In both submucous and interstitial
fibroids the cavity of the uterus is encroached upon--a fact to be
determined by the use of the sound. The history of the case will throw
some light upon the differential diagnosis. Frequently, however, it is
impossible to exclude fibroids by any of the means already mentioned.
Dilatation of the cervix, and the careful examination of the walls by
the finger introduced into the uterine cavity, will clear up the
diagnosis in the most obscure case.
PROGNOSIS.--The prognosis with reference to life is favorable. The
duration of life however, may be abbreviated in exceptional cases by
{457} disturbances of nutrition, anæmia the result of menorrhagia and
metrorrhagia, extension of the inflammation to the peritoneum, and the
like--conditions which predispose to some intercurrent affection.
Although the immediate danger of death is minimal, the woman is
rendered wretched by the frequent exacerbations of acute inflammation
and other symptoms already mentioned. The spontaneous disappearance of
the affection with the puerperium or menopause is of such seldom
occurrence as to have but slight bearing on the general rule.