Chronic endometritis usually follows the acute form. The acute symptoms subside, but leave in their wake a very definite pathology and distressing symptoms of the chronic disorder. There are many cases in which a history of an acute attack can not be obtained. If such was ever present it was insignificant and unnoticed. The causes of such cases apparently developing without acute incidence are:

(1). Deranged Spinal Innervation. By disturbing vaso-motor nerve supply a congestion of the uterus is produced. This of itself will in time lead to a chronic inflammation or more properly a proliferation of connective tissue.

(2). Constitutional Debility from disease, overwork, poor food, repeated childbearing or prolonged lactation, if not actively causative are important predispositions.

(3). Impeded Respiration. Pelvic circulation is to a large extent dependent upon full and free respiratory activity. Whatever interferes with this tends to cause pelvic congestion. It may be insufficient exercise, improper corseting, bands about the waist, postural defects, diseases of heart and lungs, etc.

(4). Pelvic Inflammation or Tumor. These when they do not directly involve the uterus do tend to cause chronic congestion of this organ.

(5). Injuries to Cervix or Uterus. Chronic infective processes may follow laceration of the cervix or lesser injuries in premature or normal births, difficult or complicated labors, instrumental examination, attempts at abortion or the improper use of pessaries.

(6). Disregard of the Laws of Sexual Hygiene. Excessive venery, masturbation or the use of various methods for the prevention of conception.

(7). Subinvolution. This is a rather frequent cause and of itself arises from improper care of the patient during the puerperium.

Pathology

Chronic endometritis, if of long standing, has extended beyond the endometrium and has involved the muscular structure of the uterus and has become a chronic metritis as well. As such it may involve the entire uterus or the pathology may preponderate in either the cervix or the body. If localized in either of these it is more frequently in the cervix, as it is more subject to trauma during childbirth, and is subject to irritation whenever there is a prolapsed condition of the uterus. Next in frequency the entire uterus is affected, the body alone, least frequently.

The mucous membrane is congested, dark red in color, soft, and owing to its swollen condition it may protrude from the external os and form a red and inflammed area around it. This was formerly thought to be ulceration of the cervix, but is now called an "erosion" or a "granular os" (real ulceration of the cervix is due to an irritation, as from a pessary, friction of the clothing when prolapsed, an unusually irritating discharge, chancroid, chancre, tuberculosis or malignancy). The glands of the cervix are hypertrophied and in a condition of hypersecretion. The ducts of the glands often become occluded and small cysts filled with glairy, viscid, cervical secretions are formed. These crysts may vary in size from a pinhead to a pea and often project beyond the external os.

When the body is affected the mucous membrane is thickened, soft and contains many enlarged blood vessels. It may also be raised in ridges or is rough and nodular, from the cystic and hypertrophied glands, or there may be patches of granulations studded over it. All this causes a leucorrhoeal discharge as well as a tendency to profuse or irregular bleeding. As a later change there may be infiltration of cells into the mucous membrane. The organization of these cells into connective tissue and the subsequent contraction of this tissue may largely destroy the gland tissue of the endometrium. As a result of the extension of the congestion to the uterine walls there is cellular infiltration within them with the formation of connective tissue. This occurs between the muscle bundles and causes the uterine walls to thicken and the uterus to become enlarged. This condition may be confined to the cervix or may affect the entire organ. As a secondary change the proliferated connective tissue may contract and a condition of sclerosis or atrophy of the uterus occur.

Symptoms

These are very insidious in their onset. The disease develops slowly and is usually well established before a physician is consulted. They are local, due to the direct effect of the inflammation, and constitutional, or reflex, due to irritation of the abundant supply of pelvic sympathetic nerves.

Leucorrhoea is often the first and most troublesome symptom and the one from which the patient seeks relief. This may have lasted for months or years and be the only symptom. If this is from a cervical inflammation the fluid resembles the raw white of an egg; is thick, glairy and tenacious. If it is from an inflammation of the body it is thin, serous, milky in appearance or in the most troublesome cases, purulent. -The discharge is sometimes brownish or reddish from a mixture with blood. It is sometimes very irritating to the external parts with which it comes in contact and may cause almost intolerable itching and burning.

Menstrual disorders are a common and important symptom. No particular disorder is constant. Depending upon the pathology present the flow may be scanty, profuse, irregular, suppressed, or as is often the case, prolonged and painful.

Pain or discomfort is common. There may be a sense of heaviness, weight, bearing down or cramplike pains in the uterus. Pain in the back, loins, legs and hypogastrium is frequent. The patient is easily tired and her endurance for physical exertion of any kind is lessened. The irritation may extend to the bladder and cause frequent urination and sometimes severe dysuria. These symptoms are worse just before and during the menstrual period.

Sterility is a frequent accompaniment. Not only does the inflamed mucous membrane offer a poor nidus for the lodgement of the ovum, but the leucorrhoea has a tendency to destroy or dislodge the spermatozoa.

The reflex symptoms are some of the most distressing produced by the disease. This is not surprising when the extensive sympathetic connection is remembered. The appetite is lost or capricious and digestive disturbances, even to nausea and vomiting, may be present. Constipation, headache, disorders of vision, pains in the eyes, irritability of temper, restlessness, sleeplessness, melan cholia, hysterical manifestation, mental and physical fatigue, and breathlessness on exertion may all be found. All of these symptoms are not found in every case, but a number of them will be present. In some cases the mammary glands may become tender, the areolae may become more pigmented and extensive. These symptoms in connection with the increase in the size of the uterus and the nausea and vomiting may lead to a mistaken diagnosis of pregnancy.

Diagnosis

On bimanual examination the cervix is found to be enlarged and tender, the os somewhat patulous, as a rule, and the soft, protruding mucous membrane, studded with the enlarged and cystic glands can be felt. The body, if involved, is enlarged, unless a sclerotic change has occurred, and is often very tender, when pressed between the fingers of the two hands. If a speculum is introduced the os will be found filled with a thick tenacious plug of mucus or pouring from it will be the serous or purulent discharge.

Differentiation must be made from fibroid tumors, tuberculosis of the uterus and cancer. The first is usually easy as the tumor will be discovered on careful bimanual examination. Chronic endometritis may exist with a fibroid. Cancer is rare before thirty-five. Its tissue is friable, and bleeds easily. It is accompanied by an abundant thin, watery and pe culiarly offensive discharge. The early diagnosis of cancer is a matter of such great importance that if there is any question, a piece of the tissue should be subjected to a microscopical examination by a competent microscopist.

Tuberculosis of the uterus is usually associated with a similar condition of the tubes and pelvic peritoneum. Tubercular bacilli may be found in the discharge or scrapings removed by a curette.

Prognosis

Relief can almost invariably be given, and a cure effected in time, though the symptoms often return. If there is an extensive laceration of the cervix an operation for its repair is necessary.

Treatment

First of all is removal of causes. After this is done intra-pelvic technic to restore pelvic circulation, lymphatic drainage and tone to the affected structures is necessary. All displacements should be corrected and all adhesions relaxed. Thorough mobility of the uterus should be secured. It should be bimanually moved in all directions, gently but thoroughly. The uterus itself, both cervix and body should be manipulated between the external and intra-vaginal hands by alternate pressure and relaxation gently applied by circular motions executed by the external hand while the internal fingers steady the organ and apply counter pressure. A sweeping movement from the sides of the uterus out ward toward the walls of the pelvis executed by the fingers of both hands simultaneously, the broad ligaments with their contained blood vessels and lymphatics being between them, aids greatly in relieving the congestion and inflammation.

The effects of these treatments should be carefully noted. If no irritation is excited the treatments may be given three times a week. If irritation is excited it should be allayed by spinal inhibition, hot applications to the hypogastrium and hot douches, and rest in the recumbent posture, before the treatment is repeated.

The cystic glands in some cases will require opening. This should be done through a speculum with a bistoury or some other sharp instrument. The operation should be done under antiseptic precautions and followed by the application of tincture of iodine or a copious douche of hot water.