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 Krause29 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 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).
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. Veit30 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.
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. Subinvolution is increased. Menstruation recurs soon after pregnancy, and the chronic metritis is aggravated.31
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.