SECTION V.-Continued. AFFECTIONS OF THE UTERUS. CHAPTER XXX. METRITIS, ACUTE AND CHRONIC: SUBINVOLUTION. LITERATURE. Barnes-Op. cit., p. 507. Bennet, J. H.-Practical Treatise on Inflammation of the Uterus: London, 1853. De Sinéty--Op. cit., pp. 315 and 351. Gallard--Traitement de la Métrite Chronique. Bull. gén. de thérapeut., etc., 1879, T. XCVII. 4 --12 liv. Guérin--Ann. de Gyn., 1878, Tom. II., p. 9. Klob-Op. cit., S. 124; Scanzoni-Die chronische Metritis: Wien, 1863. Schræder.-Op. cit., S. 84. Simpson, Sir J. Y.-Op. cit., p. 585. Thomas-Op. cit., p. 307. DEFINITION.-Inflammation in the muscular coat of the uterus leading, when chronic, to increased formation of connective tissue. The uterus is enlarged and may be of the size of a goose's egg; it is thickened, especially antero-posteriorly, and of a doughy consistence. The peritoneal surface is usually covered with lymph. On section the muscular wall is thickened, but soft and pulpy; the cut surface is of a bright red colour, shows the veins to be engorged, and yields on compression a yellowish red exudation. The mucous membrane is thickened and vascular, but the cavity of the uterus is not altered in size. Microscopically, the muscular bundles are infiltrated with pus corpuscles. ETIOLOGY. Acute metritis is produced by extension of inflammatory action from the mucous or serous lining of the uterus to the intervening muscular tissue. It occurs most commonly as part of the general inflammation produced by absorption of septic matter during the puerperium. It also arises from exposure to cold at a menstrual period-the active congestion passing readily into acute inflammation, from gonorrhoeal infection and immoderate sexual activity. Frequently it is the result of surgical interference :-careless use of sound, intra-uterine injections, pessaries and sponge-tents; scraping the uterus for the removal of submucous fibroids, operations on the cervix; and even after vaginal injections of too hot or too cold water. SYMPTOMS. There is fever and general constitutional disturbance varying with the intensity of the inflammation. The onset may be marked with rigors. There is a sensation of fulness, weight, and burning heat in the pelvis ; pain in the hypogastric and sacral regions, aggravated on movement of the body or emptying the bladder and rectum; nausea and vomiting, diarrhoea and tenesmus of rectum and bladder. Menstruation is suppressed in those cases where the metritis is occasioned by exposure to cold at the menstrual period. In other cases it is diminished in amount; exceptionally, there is menorrhagia. PHYSICAL SIGNS. There is tenderness on pressure in the hypogastric region. On vaginal examination, the vaginal walls are hot and dry, the cervix is swollen and movement of it causes pain; there is tenderness in all the fornices. The bimanual examination cannot be made on account of the pain and the resistance of the abdominal walls; if the patient be put under chloroform, the uterus will be felt to be enlarged but freely movable unless fixed by old adhesions (Fig. 206). The sound should not be used, as it causes hemorrhage from the vascular mucous membrane. PROGRESS AND TERMINATION. The acute symptoms do not last usually more than a week. The fever and pain diminish; there is less heat in the pelvis and vagina, and leu corrhoeal discharge becomes free. As complications, there may be catarrh of the bladder, rectum, or vagina. The acute usually passes into the chronic stage to be immediately described; though sometimes, under proper treatment and care, there is resolution with absorption of the exudation; rarely does it terminate in abscess formation. Circumscribed abscesses in the uterine walls-recorded by Scanzoni, Reinmann, Bird, Ashford, Schroeder, Macdonald, and others are sometimes produced and burst into the uterus itself; or adhesions may form and perforation take place into the bladder, vagina, rectum, and intestines, or even through the abdominal walls. DIAGNOSIS. The diagnosis that there is acute metritis and nothing more, is a refinement to which few would lay claim. But if the symptoms and physical signs are as described above, if the uterus be freely movable and no deposit is felt in the fornices, we may conclude that acute metritis is the prominent lesion. The possibility of abscess-formation should be kept in view. PROGNOSIS. The immediate result will depend on the extent to which the peritoneum is involved. Even when the attack is not severe, the liability to pass into a chronic intractable condition makes us guarded in giving an opinion as to complete recovery. TREATMENT. If the metritis is supposed to be due to a septic cause, the first measure indicated is the removal of that cause. Thus if it come on during the puerperium, if the lochia are fetid and we suspect that a portion of the placenta has been retained, the uterine cavity should be washed out with an injection of 1 to 40 carbolic solution. Great care must be taken not to introduce air with the injected fluid. In all cases of metritis, the inflamed uterus must be kept at rest. This is done by keeping the patient recumbent. The bowels are evacuated by an enema-not by purgatives-followed by a morphia suppository. Pain is relieved by warm fomentations, to which turpentine may be added, applied over the lower part of the abdomen; but if it be severe, the patient |