METRITIS

METRITIS (from Greek metra-uterus), more correctly myometritis or mesometritis (metritis, mesometritis, myometritis), inflammation of the middle muscular layer of the uterus (myometrium). If one adheres strictly to the patho-anatomical point of view on the essence of inflammatory processes, then not all diseases that clinicians consider metritis can be interpreted as inflammatory. Only two clinical forms will correspond to the patho-anatomical concept of metritis: acute metritis and its final stage, chronic metritis, since in them the clinical picture and anatomical changes undoubtedly have an inflammatory character. As for other diseases of the myometrium in which clinically all signs of metritis are present (enlarged spherical uterus of firm consistency, leucorrhea, menorrhagia, pain in the lower abdomen, etc.), but there are no signs of inflammation, such diseases should more correctly be isolated into a special group, calling them trophic, idiopathic, or better, functional diseases of the uterus. These include "metritic" changes in retroflexions and prolapses of the uterus, in the so-called working hypertrophy, in insufficient involution of the uterus after childbirth or miscarriage, etc. (see Uterus, functional diseases). Acute metritis is almost exclusively a bacterial disease. Among infectious agents, septic bacteria should be placed in first place here; besides them, the gonococcus plays an important role, more rarely are found the bacillus coli, tubercle bacilli, and some anaerobes (Streptococcus anaerobius, Bacillus perfringens). Acute inflammation of the myometrium has also been observed in cholera, typhoid, diphtheria, measles, etc. Finally, acute metritis can arise on the basis of severe poisonings, for example, phosphorus, arsenic, etc. The paths of penetration of microbes into the myometrium can be different. In puerperal forms of metritis, the most frequent, the gateway for pathogens is the infected mucous membrane of the uterus, from where microbes enter the tissue spaces, lymphatic and blood vessels of the uterine wall; pus-forming bacteria are introduced into the myometrium during curettage, dilation of the cervix, sounding, etc.; gonococci enter here by the usual, specific to them paths. In rarer cases, infection can occur by metastasis from distant parts of the body (angina). However the microbes may enter the myometrium, the inflammatory process as a rule begins with the endometrium. Metritis without inflammation of the uterine mucous membrane is almost never encountered, which is why it is more correct to speak not of metritis, but of metro-endometritis (see Endometritis).- Anatomical changes in the uterus in acute metritis (metritis of the body and metritis of the cervix) basically come down to an increase in the volume of the uterus (thickening of the walls and expansion of the cavity), and the uterus becomes soft and very succulent; on the section, the tissue of the myometrium has a pink-red color; blood vessels and lymphatic vessels are dilated, their number is increased; in places the tissue is infiltrated, sometimes in nests, more often along the course of the vessels. Puerperal acute metritis, clinically the most important form, is patho-anatomically divided into a number of separate forms, among which are distinguished phlegmonous metritis (diffuse phlegmonous infiltration of all intermuscular connective tissue), thrombophlebitic metritis (suppurative phlebitis, thrombosis of veins) and lymphangitic metritis (process in the walls and lumen of lymphatic vessels filled with necrotic masses and microbes). For details see Puerperium. The clinical picture of acute metritis in severe septic diseases (puerperal), as well as in acute infections (for example, cholera, typhoid, etc.) is completely covered by the severe symptoms of the main disease. In the mentioned diseases, due to the severity of the main disease, the manifestations of acute metritis recede into the background and are not recognized. Independent acute metritis also does not give any characteristic clinical symptoms. The clinical symptom complex is basically composed of the following signs: elevated temperature, enlarged uterus, increased sensitivity on palpation, succulence and swelling of the tissues, purulent discharge, bleeding, pain in the sacral region, pain in the lower abdomen, in the depth of the pelvis, i.e., symptoms characteristic of a whole range of diseases of the female genital apparatus.- Treatment of acute metritis is strictly conservative: rest, bed rest, ice on the abdomen, care of the intestines, narcotic drugs (morphine, papaverine, pantopon). Active local therapy is contraindicated.- The acute inflammatory process in the myometrium can end in recovery or pass into a chronic stage. In rare cases, in addition to these outcomes in acute metritis, two diseases are observed that are similar in clinical picture, which are also final stages of metro-endometritis - uterine abscess and the so-called dissecting metritis, or uterine gangrene (metritis dissecans, s. gangraena uteri puerperalis partialis). Uterine abscesses are most often found in septic infection in the puerperium and much less frequently in tuberculosis and gonorrhea. Cases of metastatic uterine abscesses (after angina, appendicitis) have been described. Uterine abscesses, single and multiple, in essence represent one of the stages of acute metritis. Usually, after passing through the subacute phase, it more often passes into a chronic form, while in some cases, with violation of the integrity of the granulation belt between the muscular tissue, the intermuscular tissue of the myometrium instead of serous infiltration is completely or only in limited areas impregnated with seropurulent fluid. Such abscesses are more often located near the mucous membrane, then breaking through into the uterine cavity (most favorable outcome). More rarely they are localized near the serous covering of the uterus. In such cases, the rupture can occur in the direction of the abdominal cavity with subsequent development of general peritonitis. Sometimes the development of the latter is prevented by the formation of adhesions of the intestinal loops with the uterus. With localization of the abscess near the parametrium, parametritis can develop upon rupture. In the case of Franke, the uterine abscess opened into the rectum. Small uterine abscesses can resolve, turning into scar tissue. The dangers associated with the emptying of uterine abscesses are self-evident. If a uterine abscess is accurately diagnosed, surgical treatment is recommended (amputation of the uterus above the vagina or its complete removal). Dissecting metritis, or uterine gangrene (first described by Syromyatnikov in 1880), is a severe septic disease (mortality 27-30%), occurring exclusively in the puerperium and characterized by the rejection and expulsion of necrotic pieces (sometimes with profuse bleeding) of muscular tissue. The disease is rare (in the literature only about 70 cases are described), although it should be thought that it occurs more often than described, but is often overlooked. For example, Bekman, who worked specifically on this issue, in 1897 had 4 cases of uterine gangrene out of 143 cases of puerperal diseases. In 3 years he collected (material from the Obukhovskaya Hospital in Leningrad) 12 cases. In dissecting metritis, as well as in uterine abscess, the integrity of the granulation belt is violated, due to which microbes (mainly streptococci, often bacillus coli) gain access to the lymphatic and blood vessels of the myometrium. But according to some recent authors, such a rupture of the granulation layer requires a constitutionally prepared soil (diabetes, syphilis). The further advancement of bacteria into the general bloodstream is hindered by the uterine muscle itself, in which a new granulation belt is formed. The delimited, remaining outside the limits of the granulation layer part of the muscle dies off, gradually separates from the normal tissue and is expelled from the uterus. The size of the sequestrum varies. In individual cases, the pieces expelled from the uterus represented a complete cast of the inner surface of the uterus with clearly distinguishable openings of both tubes and the internal os. Cases have been described when necrosis involved the entire thickness of the uterine wall to the serous covering.- The disease usually begins on the 3rd-4th day after childbirth with high temperature (39-40°), frequent pulse, headache, severe general condition; lochia with the strongest odor. On the 4th week, sequestration occurs: the necrotic area of uterine muscle is expelled outward. After that the temperature falls, the uterus contracts to normal, the general condition also improves. Among the complications observed in metritis dissecans, general sepsis, pelveoperitonitis, diffuse peritonitis (gangrenous perforation into the abdominal cavity), profuse bleeding should be kept in mind. Upon recovery, infertility (to this day not a single case of repeated pregnancy after uterine gangrene has been described) and amenorrhea (atresia and atrophy of the uterus and its cervix) remain for life.- In differential diagnosis, gangrenous endometritis, retention of placental fragments, and the presence of a necrotic myoma should be kept in mind. The diagnosis is established on the basis of the clinical picture.- Therapy: conservative, expectant treatment and general strengthening measures. Some recommend constant irrigation according to Snegirev. Active local therapy (irrigation of the uterus with alcohol) is contraindicated. Chronic metritis. If acute metritis patho-anatomically represents a clearly expressed inflammatory process with a definite microbial etiology, then chronic

Metritis in this respect still to this day does not constitute a sufficiently established nosological unit. Chronic metritis can develop secondarily as the final stage of a subsided acute infection in the myometrium; it can also arise as an independent disease, especially with a weakly expressed infection. These bacterial forms of metritis should be considered true chronic metritis: in them, the myometrium exhibits all the anatomical signs of inflammation. Moreover, in such cases, an inflammatory process is almost invariably found simultaneously in the area of the appendages, the surrounding peritoneum, and in the area of the pelvic peritoneum. Infectious forms of chronic metritis, together with chronic endometritis (the anatomical, etiological, and clinical separation of these two uterine diseases should be considered artificial) are often encountered (about 20% of all female diseases). The uterus in chronic metritis appears enlarged (hyperplasia of the intermuscular connective tissue), dense; clinically there is increased secretion (leukorrhea) and profuse bleeding (of the menometrorrhagic type). Patho-anatomically, two stages have long been distinguished: the stage of infiltration and induration. In the first, there is excessive development of the intermuscular connective tissue (hyperplasia), reduction of muscle fibers, expansion of the uterine cavity, and severe engorgement with blood (active and passive hyperemia), with small-cell infiltration. The stage of induration is characterized by processes of shrinkage and scarring of the connective tissue. In both stages, angiosclerotic changes (proliferation of tunicae mediae et adventitiae) are sometimes observed, with which some authors associate the reduced nutrition of muscle fibers, their death, and replacement with connective tissue. From this infectious form of chronic metritis, one should distinguish a fairly frequently encountered group of other diseases of the myometrium, in which anatomically and clinically there is also enlargement of the uterus, increased secretion, bleeding, but without signs of inflammation either in the past or in the present. Etiologically, these diseases must be associated with functional, hormonal, trophic, and other non-infectious factors. Pankov proposed to isolate all such diseases of the myometrium with a uniform clinical picture, in which one symptom (bleeding) predominates, into a special group, assigning them the name of chronic hemorrhagic metropathies (see Uterus, functional diseases). The diagnosis of chronic metritis (metro-endometritis) is made by clinicians very often, but the question of the nature of the patho-anatomical process in each individual case often presents considerable difficulties. Only a carefully collected and, above all, properly interpreted anamnesis and comprehensive objective examination will enable the physician to understand the patho-anatomical picture. Therapy. The usual anti-inflammatory treatment is applied (sexual and physical rest, care of the bowels, hot douches, tampons with a 10% solution of ichthyol in glycerin); subsequently, one can recommend, especially for gonorrheal metro-endometritis, intrauterine injections according to Grammatici, and finally physical methods of treatment (diathermy, ionization, mud therapy, etc.). Of medicinal preparations, preparations of ergot (Secacornin, Ergotamin, Gynergen, Ergotin), Hydrastis canadensis, Styp-ticin, Mammin, etc., are usually used. Adler recommends enemas with ergot (Ergotini dialysati spissi 5.0, Aq. dest. 35.0, Ac. salicylici 0.1, Glycerini 10.0); after an evacuating enema, introduce per rectum (a coffee spoon), previously mixed with two tablespoons of water,

M. Malinovsky. «► -*►