(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 he 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, melancholia, 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 peculiarly 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 he 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 bimanuaily moved in all directions, gently but thoroughly. The uterus itself, both cervix and body should he 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 outward 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 he 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.

Fig. 45. Left-sided Pyosalpinx.

Fig. 46. Double pyohydrosalpinx, Chronic Adhesive Perimetritis and Oophoritis. Both tubes are almost filled with pus, the fimbriated ends, walled off both from the isthmus and from the peritoneal cavity, are transformed into cysts. (Schaeffer, Atlas and Epitome of Gynecology.)

Chronic salpingitis is nearly always the result of the acute form.

PATHOLOGY. The tubal epithelium is diseased the walls are infiltrated and thickened by inflammatory exudate which may have become organized into connective tissue. The inflammation may have closed one or both ends of the tubes, the fimbriated end, usually first. Any serous exudate which had accumulated within the lumen of the tube may have become absorbed, or similar pus collections become sterile, unless due to streptococcus infection. Should these changes not have occurred a hydro-salpinx, pyo-salpinx or ovarian abscess may remain. Again the conditions within the tube may have subsided leaving as sequelae peritoneal adhesions which may bind tubes and ovaries into a distorted and displaced or immobile mass. (Figs. 45, 46)

SYMPTOMS. These are often vague and indefinite. There is usually tenderness or pain in one or both of the iliac fossae; or perhaps generally over the lower abdomen, with a sense of weight and heaviness in the pelvis.  Backache is not uncommon. These symptoms are all aggravated by exertion of any kind, or by standing, and usually by the onset of menstruation. Leucorrhoea is often present. Sometimes there may be an occasional gush of muco-purulent fluid, perhaps due to the discharge of an accumulation of fluid in the tube. Menstrual disturbances are common. Sterility is to be expected. There is usually some deterioration of the general health with loss of flesh and strength and often neurotic symptoms. Acute exacerbations of the symptoms may occur from time to time from various causes.

DIAGNOSIS. This is determined finally by a bimanual examination. In mild cases the tubes may be found in a thickened or nodular condition as slightly tender cards passing out from one or both cornua of the uterus. Again a sausage shaped sensitive mass will be detected, more or less mobile, and easily recognized as an enlarged tube. If the tube is filled with fluid a mass may he found beside the uterus by which it may be adherent to the pelvic wall. The mass may be pear shaped, the small end toward the uterus, the large end formed by the dilated tube adhering to the ovary. Often the tube has gravitated to the recto-uterine excavation where it may be fixed by adhesions. When it contains fluid, fluctuation can usually be elicited.

The ovary can sometimes be felt free of adhesions, tenderness or swelling, but it is usually more or less affected, and in tender, swollen, involved in adhesions and matted to the tubes.

A recto-abdominal examination is of aid in making a diagnosis.

TREATMENT. This has been discussed in the Chapter on Adhesions.

This disease occurs more frequently associated with chronic inflammation of the pelvic peritoneum and connective tissues than as an affection of the ovaries alone. Both organs may be involved, but when the disease is unilateral the left ovary is more frequently affected. This is because of its proneness to congestion, the left ovarian vein not only being without valves, but it opens into the renal vein at right angles, and because of its location it is subject to pressure from fecal accumulation in the lower bowel.

The disease is most common in married women and during the age of sexual activity.

CAUSES. (1) Deranged spinal innervation.

(2). Pelvic inflammation, especially gonorrhoeal or puerperal. Endometritis, salpingitis, cellulitis or peritonitis may cause ovaritis by extension, the two former by extension through the tubes, the latter by continuity of tissue.

(3). Uterine Displacements by causing congestion. Retroversion especially as it not only greatly distorts the course of the blood vessels, but also displaces the ovaries.

(4). Prolapse of the ovary by producing congestion and irritation.

(5). Repeated attacks of acute ovaritis.

(6). Continued congestion. This may be from intemperate coitus, masturbation, unsatisfied sexual desire or severe exertion, heavy lifting, alcoholism, heart, lung or kidney disease.

PATHOLOGY. The disease may occur primarily as a disease of the ovary or a disease of the peritoneal covering of the ovary, or what is in fact, a peri-ovaritis. In the early stages of the disease the ovaries are congested and may be enlarged to two or three times their natural size. This enlargement may be permanent or the contraction of new inflammatory tissue within the organs themselves, together with the contraction of adhesions surrounding them, may cause them to atrophy and become smaller than normal. When enlarged the ovary is often prolapsed into the recto-uterine excavation or by the side of the rectum. It may be fixed here or in its normal position by adhesions.

Cystic degeneration is not uncommon. (Fig. 10.) The cysts may be small and multiple, or one large cyst may form and by pressure, cause atrophy of the ovarian tissue, a true ovarian cyst being formed. The cysts originate from the corpora lutea or from Graffian follicles, which are prevented from rupture because they are deeply seated or covered with inflammatory exudate, or because of insufficient menstrual congestion to, cause their normal rupture. Waxy degeneration of the ovary sometimes occurs.

SYMPTOMS. These are frequently vague and may be masked by the accompanying conditions.  Pain is rather constant. It is usually located in the groin, most frequently on the left, and radiates to the sacrum, the rectum, the bladder or down the thigh to the knee. It is increased by jolting or jarring, often by defecation or micturition and by coition, if the ovary is prolapsed. Standing or walking for even a short while is painful and difficult. The pain is always more severe preceding menstruation, sometimes several days before, and is relieved if the flow is profuse, but continues when the flow is scanty.

Sympathetic pains are often felt in the breasts.

Leucorrhoea is sometimes present as a result of the general pelvic congestion.

Menstruation may be irregular or profuse, in the early stages, but later if the ovarian tissue is destroyed amenorrhoea will result.

Reflex nervous symptoms are sometimes pronounced. Irritability, mental depression, hysteria, or even epilepsy may result.

DIAGNOSIS. This is made from the history of some previous pelvic inflammation or the operation of some of the less frequent causes; together with the tenderness and spherical enlargement of the ovary, (which increases before menstruation), the premenstrual pain, and the presence of adhesions about the ovary.

TREATMENT. In addition to the treatment as outlined under Adhesions, to free the ovary, it should be manipulated directly. This is done by making circular movements limited, if not to the painful area, at least to the ovary itself. These motions can be made by either the external or internal hand. The hand not employed in these manipulations is used to make counter pressure and to immobilize the ovary while the motions are made. When prolapsed the ovary can sometimes be more easily reached by recto-abdominal manipulation.

Efforts should be made with each treatment to replace the ovary.