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 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.
Under judicious treatment disappearance of the more distressing symptoms may be confidently expected during the stage of infiltration. The outlook is especially favorable in cases of puerperal subinvolution in the absence of chronic inflammations of the endometrium and parametrium. A perfect restitution of the uterus to its normal condition is so seldom effected by any rational therapy that for practical purposes this desirable result may be excluded from consideration. Recidiva of the disease are liable to occur at any time.
TREATMENT.—Prophylaxis.—Very much can be done to prevent the occurrence of chronic metritis. A careful consideration of the etiology of the disease will at once suggest the principles of prophylactic treatment. The conduct of the second stage of labor, the puerperium, lactation, the hygiene of menstruation, are subjects especially significant in this connection. Antecedent acute metritis and endometritis under a rational therapy usually terminate in resolution, and their pernicious influences as etiological factors may be avoided, or at least modified, in the large majority of cases. The early rectification of uterine flexions and displacement is urgently indicated in view of the probable consequences.
Uncomplicated chronic metritis is such a rare affection that efforts at curative treatment are seldom addressed to the condition of the parenchyma, to the exclusion of the endometrium, perimetrium, and parametrium. Certain special indications, however, exist in the case of chronic uterine infarct, and the discussion of treatment is limited here to their consideration.
1. Local Treatment.—In view of the pathology of the condition, local treatment, especially in the first stage, is antiphlogistic.