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 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. Fritsch13 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."
12 Ely Van de Warker, "A Gynecological Study of the Oneida Community," The American Journal of Obstetrics, etc., August, 1884.
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. 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.