Chapter XII: Front Matter (12)

While the writer would not be just to the reader if he did not state that some very high authorities are strongly opposed to intra-uterine injections and applications, he would not be just to himself did he not state that his own experience has been favorable to them. While he once saw severe and dangerous symptoms follow syringing the cervix with water to cleanse it of mucus, he never in a single instance saw any evil effects from intra-uterine injections properly administered, nor from nitrate of silver à demeure or the application of nitric acid. But while these measures have often ameliorated cases of menorrhagia where the endometrium was affected, they have seldom cured, as compared with the curette. Indeed, the general statement may be made that as of late years the value of the curette has become more and more recognized, resort to severe intra-uterine applications has proportionally diminished. From his experience he is fully prepared to believe with Courty, that "there are cases of uterine hemorrhage which cannot be mastered in any other way," and with Siredey, that "the operation cures in the great majority of cases." It should be noted, in this connection, that some of the warmest advocates of the instrument explain its beneficial effects otherwise than by the removal of fungosities. Thus, Thomas attributes them to "the fracture of tortuous and distended blood-vessels," and Siredey to "the irritation and excitation produced by its introduction and action during reflex contractions."

{208}

INFLAMMATION OF THE PELVIC CELLULAR TISSUE AND PELVIC PERITONEUM.

BY B. F. BAER, M.D.

The subject of inflammation of the tissues surrounding the uterus and its appendages would be very much simplified, especially for the general practitioner, by debarring it of all new and superfluous names and subdivisions, and by treating it on a broad clinical basis. It will be my aim in this paper to keep that idea constantly in view, rather than to follow the history and varying pathological views by which it has been surrounded and complicated.

The importance of this disease is probably greater in its influence on the health and future usefulness of the woman than any other; and its causes and prevention, as well as its early recognition and treatment, should be fully understood by the physicians who are most likely to be first consulted in the matter, those engaged in general practice. I feel safe in making the statement that were this so, many of the chronic cases of almost incurable displacement of the uterus, Fallopian tubes, and ovaries, resulting from thickened, indurated, and contracted ligaments, with their distressing symptoms, would never reach the gynecologist, because they would not then exist. In many cases the disease would have been prevented; in others it would have been arrested in its incipiency.

Whether we understand the primary pathological lesion to be inflammation of the cellular tissue, the peritoneum, the lymphatics, or the veins, matters very little, practically, if we recognize the immediate location of the process; for there can be no doubt that the disease, once started, soon involves to a greater or less degree all of the tissues and organs adjacent to it, and the therapeutic requirements will be much the same in either case.

That inflammation of the cellular tissue can exist without also involving the peritoneum in its neighborhood is scarcely to be conceived, and vice versâ; but the one has always a predominating influence over the other, and differs somewhat in its cause, course, and consequences. When the inflammatory process has its origin in the cellular tissue, it is more likely to run through a regular course and end in abscess than if it had started as a peritonitis, in which case the course of the disease is often more chronic, resulting in the formation of false membranes which bind the uterus and other pelvic organs in permanent displacement. For these reasons, and for the more systematic study of the subject, I think it best to follow the plan of those authors who describe the disease separately under the two general heads, Parametritis and Perimetritis.

{209} Parametritis.[1]

[Footnote 1: Virchow, Duncan.]

DEFINITION AND SYNONYMS.--By parametritis is understood an inflammation of the cellular or connective tissue near the uterus and beneath the pelvic peritoneum, including principally the locality close to the lateral margin of the uterus between the layers of the broad ligaments, although embracing also all of the various spaces where connective tissue abounds--viz. between the peritoneal folds which form the utero-sacral and utero-vesical ligaments. I think it a better name than pelvic cellulitis or peri-uterine inflammation, because it more correctly expresses the primary location of the disease than any other. The disease has been described under many other appellations, among which have been pelvic abscess and peri-uterine phlegmon.

ETIOLOGY.--Parametritis does not occur before puberty, and rarely before the great predisposing causes, abortion and injury at parturition, have prepared the parts--opened up the channel--for the more ready advance of the inflammatory process. This is easily understood when we remember how compactly bound together are these ligamentous folds, and how small the cellular-tissue spaces are before impregnation when compared with the condition of the parts after the function of gestation has been performed. Even were no accident to occur to interfere with the perfect involution of the parts which enter into the process of the expulsion of the product of conception, the tissues would probably always remain more vulnerable than before the gestation had occurred. But when the retrograde change which is necessary to perfect involution is retarded, a condition of relaxation and looseness of the parts results which increases many fold the liability to the affection. The blood-vessels and lymphatics remain large, and the connective-tissue cells are not only larger in size, but a cell-proliferation is probably induced as a result of the increased amount of blood-supply. Then a certain low condition of the general nutrition, a diathesis or an inflammatory tendency, no doubt act as predisposing causes of this disease. Now, add to the predisposing causes the injury which probably always attends abortion, and that which so often results from parturition proper, and a condition results which I believe to be the cause of parametritis in the majority of the cases.

Abortion the result of accident or design is a most prolific cause of parametritis, because abortion is so often followed by endometritis, which is frequently the starting-point of the former. Abortion results in a wounding of almost the entire surface of the uterine cavity, from which the placenta is torn, and often also in direct injury to the tissues of the neck of the womb. This almost necessarily interferes with involution; and if nothing worse follows immediately, there is left a strong tendency to a low grade of inflammation or hyper-nutrition, which may practically result in the same condition of induration and thickening of ligaments. It is seldom that the subject of an abortion of this character escapes from a certain degree of parametritis. If it does not manifest itself at the time in violent symptoms, the results are found afterward, when the patient is forced to consult her physician for the relief of suffering the consequence of the thickening and induration mentioned above.

{210} Parturition without injury or accident is a predisposing cause, as before mentioned, of parametritis, and renders the patient more susceptible to the disease from cold, fatigue, etc., and from septic influences; but when the labor has resulted in injury to the soft parts, as laceration of the cervix, endometritis, injury to the vessels outside of the uterus, in the broad ligaments from pressure, the disease is far more liable to follow.

Parametritis may result from the various operations on the perineum, vagina, and uterus; from the application of medicines to the uterine cavity; and it is even said that the disease has been excited by the introduction of the uterine sound. I cannot believe that the simple introduction of the sound, when properly done, can be the means of so much harm. If harm follows, it must result from carelessness or want of skill. Of course there are contraindications to the use of the sound, and if these are violated evil will often follow. The use of the instrument ought not to be thought of if a suspicion of pregnancy exists, or when there is marked tenderness of the uterus or of the parts around it, or just before, during, or immediately after menstruation, and certainly not when active inflammation is present. Then the awkward manipulation of the sound when the uterus is fixed as a result of a former inflammation is very apt to relight anew the process.

If the same restrictions are applied and care used in the medication of the uterine cavity, the cases in which parametritis will follow as a result will be almost nil. The same will apply to operations. The danger lies in proceeding with the treatment of cases as they present themselves, by a hurried method and without fully investigating the condition of the tissues and organs outside of the uterus itself.

There is probably no place where experience is of more value than in the manipulations and instrumental measures necessary for the diagnosis and treatment of the various diseases of the pelvic organs--where more depends upon the skill and care of the operator. I believe, with Duncan, that pelvic inflammation and abscess are always secondary, and that these tissues are not specially inclined to idiopathic inflammatory action. But, undoubtedly, certain low conditions of the system or certain individual peculiarities furnish such a strong predisposing influence that a mechanical cause otherwise inactive will be sufficient in some of these cases to produce the disease. We probably see this expressed most fully in the low types of puerperal inflammations which develop gradually and without apparent cause, so far as injury at labor is concerned, and which often persistently progress to a fatal termination. It will be said that these are cases of septic origin; and it may be true, but I believe the poison is developed autogenetically.

COMPLICATIONS.--Parametritis is usually associated with perimetritis, and it may be complicated by ovaritis, endometritis, and salpingitis. Uterine displacement also often complicates this disease; and I wish here to emphasize the statement that no attempt should be made at restoring the organ to its normal position until all evidence of active inflammation shall have subsided. I have seen great harm result from such attempt having been made on the supposition that the symptoms were due to the displacement rather than to the parametritis.

ANATOMY, PATHOLOGY, COURSE, AND TERMINATION.--Everywhere in the pelvis, below the peritoneum, connective tissue is found in sufficient {211} abundance to serve the purposes for which it exists--viz. first, as a bond of union between the pelvic viscera and organs, bladder, uterus, rectum, ovaries, and Fallopian tubes; second, to surround, support, and protect the numerous blood-vessels, lymphatics, and nerves from injury during the mechanical disturbances to which the pelvic tissues are subjected in the performance of their various functions.

If it were not for the padding of the pelvic connective tissue, which allows a free range of movement to the pelvic contents, the ordinary sudden jars from walking, coughing, etc. could not be sustained without pain, nor could the functions of the rectum and bladder be fulfilled properly; much less could the functions of coition and gestation be performed. This cellular tissue most abounds where it is most needed--in the locality or spaces where the vessels and nerves are found in greatest number; viz. at the sides of the uterus and upper portion of the vagina, extending outward between the folds of the broad ligaments toward the pelvic wall and the under surface of the Fallopian tubes and ovaries; next, within the folds of the utero-sacral ligaments and the vesico-uterine space beneath the peritoneum. There is little between the peritoneum and posterior vaginal wall, between the bladder and its peritoneal investment, as well as between the rectum and peritoneum; and there is none between the latter membrane and the posterior, superior, and anterior surfaces of the body of the uterus.

This areolar tissue is the seat of the disease under consideration, and from a priori reasoning it would be inferred that the inflammatory process would be found most frequently and in greatest severity in the locality where this tissue and the vessels most abound; and this is true, for parametritis almost always has its starting-point immediately at the sides of the uterus, in the lower inner edge of the broad ligaments.

But there is another reason why the disease so often begins here. It is the point, which, with the cervix, must bear the brunt of the pressure and injury during parturition and abortion, as well as from many of the operations which are performed upon the uterus. That inflammation of these tissues is secondary to injury is proven by the fact that we so often find the results of it, induration and thickening of the broad ligaments, in the cases of laceration of the cervix which come under our care. I have constantly observed that the inflammatory indurations were greatest on the side on which the laceration was most extensive, and that were the laceration unilateral the evidences of inflammatory action would be unilateral also. I have so frequently met with this condition in connection with laceration of the cervix that I have come to regard its entire absence as quite exceptional. I refer now to the deeper lacerations. Of course these inflammatory products are met with when the cervix is entire and apparently healthy, but this does not disprove the statement that they are probably invariably secondary, and very often secondary to injury at labor; for while the cervix may have escaped laceration, the tissues and vessels may have been so contused from pressure and instrumental measures as to result in the disease. But, however originated, the inflammation and infiltration advance in the direction of least resistance--_i.e._ along the course of the connective-tissue spaces between the various ligaments. The product of the inflammation, the pus, would therefore most likely follow these channels in making its exit. If the primary inflammation arise at {212} the base of the broad ligament, it may travel within the folds of the ligament outward to the lateral wall of the pelvis and upward to the iliac fossa. This is probably the course which is most commonly taken by the process in puerperal parametritis, and to which is due the induration and tumor which so often exist in that region during the course of the disease. Tumor in the iliac fossa, however, is not at all uncommonly met with in the course of a severe parametritis in the non-puerperal state, and it is doubtless of the same pathological character. Or the infiltration may propagate in the folds or under surfaces of the utero-sacral ligaments, resulting in the formation of a tumor which may eventually surround the rectum. In rare cases, and probably only in the puerperal, the process may develop higher up and more anteriorly, finally taking the direction and following the course of the round ligaments; but I have never met with an instance of it. And it would be impossible to tell correctly in a case opening in the groin--without a post-mortem demonstration, the opportunity for which, fortunately, does not often occur--whether the pus had not descended subperitoneally along the pelvic brim toward the inguinal region. Of course the inflammation and infiltration may be general, so that the uterus may be surrounded by exudation tumors, but this is the exception. Inferiorly, the parametritic process is limited by the pelvic fascia which covers the levator ani muscle.

Parametritis, as phlegmonous inflammations elsewhere, has three stages: 1st, that of active congestion; 2d, that of effusion of serum; 3d, that of suppuration. But the disease does not reach the third stage in all cases. It may be arrested in the first stage or end by resolution in the second. I believe, however, that resolution in the second stage is the exception and not the rule. First, because to end in suppuration is the natural course of the disease; and secondly, because in many of those cases which are carefully observed the ordinary symptoms of the formation of pus, as chill, etc., are usually manifested, and followed by its evacuation. The fact that pus is not discovered should not be accepted as proof that the disease has not advanced to the suppurative stage; for it may be so small in quantity as to escape observation, or it may be discharged into the bowel so high up as to mix with the fecal matter, so that its character is lost by the time it is expelled from the anus, or the point of exit may be so small as to allow it to escape guttatim, and thus elude detection.

Further, pus is sometimes formed and reabsorbed harmlessly, or it may remain deeply seated in a cavity--usually, under these circumstances, a number of small cavities--where it may undergo decomposition and result in the absorption of septic material and destruction of the patient before it finds exit. Then, again, it may become encysted and be retained indefinitely, when it is a source of constant and sometimes obscure suffering, as well as an abiding cause of a renewed attack of the disease.

It is probable also that the process is sometimes arrested in the second stage, neither resolution nor suppuration taking place, the serous portion of the liquor sanguinis being absorbed, the remainder undergoing a change to plastic lymph, so called, which proceeds to organization, resulting in persistent induration of the affected parts; or, instead of being absorbed, the serum may remain encysted within cavities formed for it by the lymph. This likewise subjects the patient to the constant menace of a renewal of the inflammation. The late D. Warren Brickell of New {213} Orleans has called special attention to what he named the serous form of pelvic inflammation, and which he thought had been too much neglected.[2] I have met with at least one well-marked case which supports Brickell's views.

[Footnote 2: "The Treatment of Pelvic Effusions," _Amer. Journ. of the Med. Sciences_, Philada., April, 1877.]

The usual course, however, of an acute parametritis which has advanced to suppuration is evacuation of the pus by the most favorable channel--_i.e._ through the rectum or vagina. If through the latter organ, the point of perforation is either directly posterior to, or a little to the side of, the cervix. But if the inflammation be located in the vesico-uterine space--which is rare, however--the point of rupture may be anterior to the cervix. Less frequently the bladder is perforated and the pus discharged with the urine. More rarely the abscess is discharged through the abdominal wall, groin, or saphenous opening, and still more rarely through the sacro-ischiatic and obturator foramina. It may also find exit through the floor of the pelvis near the anus, and it may rupture into the peritoneal cavity, but the latter termination is fortunately the least common. This is probably due to the fact that the slightest irritation and pressure, under these circumstances especially, result in adhesive inflammation between the peritoneal surface of the abscess and that of the intestine with which it may be in contact, thus favoring rupture into the intestinal tract. Then, rupture into the intestine is conservative and protective, and the other is not, for should the pus be discharged into the peritoneal cavity the patient would most likely perish.

When the abscess opens at its most dependent portion, which is the rule, it is kept thoroughly drained of the pus, and if a single cavity exists it gradually contracts, and under favorable circumstances soon disappears, the trouble ending by absorption of the wall of the abscess. This is the most favorable termination of a parametritis, and belongs only to the acute form.

When the pus has not been evacuated from the bottom of the sac, or when there is more than a single cavity and only one is drained, or where the pus has taken one of the circuitous routes mentioned above, the disease merges into the chronic form, and may then be indefinitely prolonged by the formation and evacuation of abscess after abscess, until the pelvic cellular tissue becomes involved throughout and riddled by fistulous tracts connecting them.

SYMPTOMATOLOGY.--Pain is probably the first symptom to attract the attention of the patient, and if the attack is sudden or acute the pain is usually attended by a chill of more or less severity. The pain may be so sharp and lancinating as to cause the patient to cry out in agony, or it may be of a throbbing, aching character. If the former, it indicates either intense congestion of the vessels and tissues involved, or that the peritoneum is largely implicated, probably both. Where the pain is of this character the attack is usually of shorter duration, since it is soon followed by the second stage, exudation, when the symptom is at once modified, becoming less acute and resembling now the pain attending an attack of less severity. Of course the location of the pain corresponds to the seat of the inflammatory process. If it is in one or the other broad ligament, the pain is greater in the right or left iliac regions, most {214} frequently in the left. Pain is often experienced in the hypogastric and sacral regions in the beginning of, or preceding, an attack of parametritis, and it is due to congestion of the endometrium and uterus, from which the disease is spreading to the looser cellular-tissue spaces in the ligaments. If, however, sacral pain persists throughout the course of the disease, or exists in that region chiefly, it indicates that the inflammation has become general or has invaded the utero-sacral ligaments. But it would not be correct to estimate the extent of the disease by the amount of pain complained of, for that symptom depends so largely upon the temperament of the patient and her station in life that it is not trustworthy. Some women suffer so much that they become inured to it or acquire the habit of suffering in silence; others, from temperament, do not actually experience pain; whilst others, again, from a love of hardihood, do not complain, although they may be enduring constant and severe pain. To one of these classes those cases must belong which are said to pass through an attack of parametritis without suffering. That cases do rarely present themselves, on account of mild but persistent symptoms, which are found on examination to contain a large pelvic exudation, I can attest; but I have so constantly found on careful questioning that the usual symptoms of pelvic inflammation were present at some time during the course of the existing illness that I cannot agree with the statement made by some authors that this disease may develop "without causing any particular disturbance" (Emmet).

As a rule, the bladder and rectum are reflexly affected, the former sometimes becoming very irritable, so that there often exists a constant desire to micturate. Constipation is the rule, though I have known a severe diarrhoea to accompany the disease, the result, I thought, of reflex irritation. The stomach also is often sympathetically affected, nausea, and sometimes vomiting of an aggravated form, being present.

With a subsidence of the chill the temperature begins to rise, and continues to increase, with evening exacerbations, until it reaches 102° to 103°, usually its highest point. It may, however, rise suddenly and reach as high as 104° or even 105°--rarely above the latter point. The pulse is usually full, and beats from 112 to 120 per minute, sometimes oftener.

In severe cases tympanites exists, with great tenderness in the hypogastric region; the thighs are also flexed upon the abdomen to protect the parts from pressure and to relieve the abdominal muscles from tension. But when these symptoms are marked it may be confidently concluded that the peritoneum is extensively involved.

Within a few days to a week from the initial symptoms the stage of effusion is probably completed or well advanced, when the symptoms are usually ameliorated. Pain is diminished and the temperature decreased, and if, happily, resolution begins, the patient may gradually recover during the succeeding two or three weeks. But, unfortunately, this very favorable course is not the usual one. Instead of it, the disease often advances to the third stage, that of suppuration. This stage is very commonly ushered in and manifested by rigors or chill, followed by a rise in temperature and an increase in the pulse-rate. There may now be daily afternoon exacerbations of temperature, followed by sweating, until the pus is disposed of, usually by evacuation.

PHYSICAL SIGNS.--If an opportunity is afforded for making a vaginal {215} examination during the first stage, it will be found that the local temperature is markedly increased, that great tenderness exists, and that the parts involved are rigid from congestion. A little later this rigidity or erection subsides, and a bogginess may be discovered at the point or points where effusion is now taking place. Still later, a rather firm and, it may be, irregular swelling of variable size and location can be detected, usually in one of the broad ligaments, and from the size of a hen's to that of a goose's egg. If the inflammation has existed on both sides of the uterus, the pelvic roof, so called, may be found as hard and firm as a board. If pus has formed, fluctuation may be felt, and later a softening process may be detected, indicating the point where Nature is attempting to rid herself of the product of the inflammation.

The uterus is usually displaced by the exudation to an extent depending upon the size of the swelling, to which it is fixed more or less firmly. If the effusion has taken place in one of the broad ligaments, the organ will be displaced to the opposite side, but if the inflammatory process has extended to the cellular tissue in the posterior region of the cervix and in the utero-sacral ligaments, the organ may be displaced forward as well as laterally. If the cellular space between the bladder and cervix alone be involved in the inflammation, the resulting effusion may displace the uterus backward, but the disease is rarely met with in this location. Retroversion of the uterus frequently complicates parametritis, but in that case the abnormal position is not necessarily due to displacement by the exudation. It may have existed previous to the attack.

It must not be forgotten, however, that the symptoms and physical signs, as described above, apply only to the acute form of the disease, and that they do not exist in the same degree nor in the same regular order when the inflammatory process has been subacute, as it often is, from its commencement. When the disease is subacute from the start, the patient may be enabled to go about, and even to pursue a laborious occupation, but not without suffering. There will always be more or less pain experienced in the affected region, and the temperature and pulse will be slightly increased. In rare cases the manifestations of the disease may be so slight or so little complained of that the physician is surprised to find, on examination, a large exudation in one or both broad ligaments.

DIFFERENTIAL DIAGNOSIS.--It is of the greatest importance that this disease should be recognized early, so that prompt measures may be taken to arrest it if possible, or at least to modify the severity of its course. Fortunately, as a rule, the subjective symptoms of pelvic inflammation are so marked that the attention is at once directed toward seeking for their confirmation by eliciting the physical signs; and for diagnosis these local manifestations of the inflammatory process are to be relied upon entirely, as the subjective symptoms of inflammation of the other tissues and organs of the pelvis somewhat resemble those of parametritis.

The diseases the local signs of which approach more nearly those of parametritis are--pelvic hæmatocele, fibrous tumor, the early stage of extra-uterine pregnancy, the early stage of parovarian and ovarian cystic degeneration, and perityphlitis.

In pelvic hæmatocele the symptoms occur suddenly, and often with hemorrhage; there are also constitutional signs of loss of blood, as pallor and coldness of the surface of the body, and if the hemorrhage is great {216} failure of the pulse and syncope. The tumor caused by the escape of blood into the pelvic cavity is generally post-uterine, distending Douglas's cul-de-sac and crowding the uterus forward toward the symphysis pubis, while that formed by parametritis is oftenest located at the side of the uterus. The hæmatocele at first is soft and compressible, becoming hard within a short time--a few days--as a result principally of the surrounding wall of lymph which nature throws out as a protection. The symptoms of parametritis, on the other hand, are more likely to come on gradually, and to present the pulse- and temperature-signs of inflammation, while the resulting swelling or tumor is rigid at first from congestion of the tissues, then hard, becoming soft later as the process advances to suppuration. Mere location of the tumor, however, cannot be depended upon; we must be guided by the history of the case and the special character of the tumor.

Fibroid tumor is not attended with the usual acute symptoms of parametritis, such as pain, increase of temperature, and accelerated pulse; the tumor is hard from the beginning, or at least never soft; it is circumscribed, usually smooth, and not sensitive to the touch. Its attachment to the uterus is also different from that of the tumor caused by parametritis. The former shows a tendency to pedunculation, while the latter has always a broad surface attachment.

The tumor resulting from the arrest and development of a fecundated ovum in the Fallopian tube or ovary resembles very much in its locality, and somewhat in its characteristics, a parametritic tumor; for usually more or less inflammatory exudation is present in connection with extra-uterine pregnancy, giving at times a fixity and hardness to the gestation-sac not unlike that sometimes observed in a tumor parametritic in origin; besides, there may also be constitutional signs of an inflammatory action. But the presence of some of the ordinary signs of pregnancy and a little time will clear up the difficulty; for as the case progresses the tumor will increase in size and change in character, while the mammary and other signs of gestation will develop. In addition, the pain attending tubal pregnancy is never like that of parametritis: it is more persistent, lancinating, and cramp-like in character, and is unattended by rise in temperature. Soon also the placental bruit may be detected, which of course never exists in parametritis.

The early stage of normal pregnancy is said to have been mistaken for this disease. I can hardly conceive how this mistake in diagnosis could be made, although I have met with several cases where the congestion consequent upon fecundation was so violent as to result in actual pelvic inflammatory symptoms with subsequent exudation.

The following case, which I saw with H. A. M. Smith of Gloucester, N. J., markedly illustrates and confirms this opinion: Mrs. B----, æt. 21, had been married five years, but had never conceived. Her catamenia had always been regular in time, but the flow had been slight in quantity. In the latter part of November, 1884, or about three months before I first saw her, she was attacked with severe pain in the pelvis, accompanied by rise in temperature and accelerated pulse. She was compelled to go to bed, where she had remained up to the time of coming under my care. During this time she suffered from great tenderness over the hypogastrium, some tympanites, and considerable nausea and vomiting. She {217} did not menstruate in November--the period was due when she was first attacked with pain--but in December she had severe uterine tenesmus and a profuse metrorrhagia--symptoms of abortion. Pregnancy had not been suspected, however, as she had been so long sterile, and the inflammatory symptoms had been so violent that the signs of gestation had been masked by them. At the time of my first visit (March, 1885), there was great tenderness of the hypogastrium with slight tympanites; nausea and at times vomiting; great nervous prostration; loss of flesh; menses absent since November, except the uterine tenesmus and hemorrhage in December, as above stated; and at each menstrual cycle afterward she had the symptoms of uterine contraction with a profuse leucorrhoeal discharge, but no hemorrhage. The mammary glands showed the usual signs of gestation at about the fourth month; the vagina was purplish; the cervix uteri low down on the floor of the pelvis, and the mucous membrane around the os hypertrophied, soft, and abraded. The body of the uterus was anteverted and symmetrically enlarged to about the size of the organ at the third month of gestation. The uterus seemed to be fixed--incarcerated within the pelvic cavity--by an indurated exudation in the lower portion of the right broad ligament. I diagnosticated pregnancy, and accompanying parametritis as a result. The treatment consisted in painting the right side of the fundus of the vagina opposite the base of the broad ligament with iodine; the application of iodized glycerin on pledgets of cotton, together with the use of the hot-water douche; internally, opium enough to relieve pain and an alterative tonic in the form of the four chlorides, the formula for which will be given at another place. She began to improve at once, but as she was still threatened with abortion and the uterus was still incarcerated within the pelvis, ether was administered for the purpose of attempting to release it. With two fingers of the left hand in the vagina and the right hand upon the hypogastrium to exert counter-pressure, gentle manipulation was made with the view of stretching the adhesions. This resulted in a slight elevation of the womb, and from this time pregnancy went on to full term without further trouble.

This case is introduced chiefly to show the possibility of the existence of parametritis with normal gestation. It is true that the inflammation, which developed simultaneously with fecundation, may have had a latent existence before the occurrence of that event, and that the stimulus of pregnancy served simply to bring about an attack of an active character, but nothing in the previous history of the case indicated such a condition.

Perityphlitis may somewhat resemble in its subjective symptoms, as pain and rise of temperature, an attack of parametritis. A careful study of the physical signs, and also of the exact position of the tumor in each case, however, ought to be sufficient to differentiate between the two diseases. The tumor of perityphlitis is always on the right side, and situated high up in the false pelvis; that of parametritis may be on either side--it is oftenest on the left--and is usually located low down in the true pelvis. The latter is easily reached per vaginam, while the former is almost or quite out of reach from this direction.

Parovarian cystic disease in the early stage, before the tumor has developed sufficiently to rise above the pelvic brim, resembles in its location parametritic exudation; but the history of development and the physical {218} characteristics of each are different. There is an absence of hardness and tenderness to the touch in the former, which always exist in the latter. Parovarian tumor develops without the constitutional phenomena of inflammation; parametritis, I believe, never.

It must not be forgotten, however, that either one or more of these various diseases may exist in connection with, and as complications of, parametritis, rendering the diagnosis at times exceedingly difficult, requiring time and patience to clear the way. A case in point may be stated in brief as follows: Mrs. H---- was sent to me some months ago. She complained of great pain in both iliac regions--more in the right--extending into the pelvis and sacrum and down the limbs. There were also menorrhagia, and profuse leucorrhoea during the intermenstrual periods. She dated the trouble from an abortion which had occurred nine years before, and which was followed by symptoms of acute parametritis, from which she never fully recovered. Physical examination showed the uterus to be considerably hypertrophied and fixed, as in a vise, by an indurated mass on either side of it, which seemed to occupy both broad ligaments or to be closely adherent to them. The cervix uteri was also badly lacerated; its mucous membrane presented a surface so hypertrophied, abraded, and jagged that I was at first strongly impressed with the fear that epitheliomatous degeneration had begun to develop. I pursued a plan of treatment designed to reduce the congestion and hypertrophy of the diseased neck, and at the same time to induce an absorption of the plastic and indurated lymph around the uterus, to render the organ mobile, so that an operation might be made safe. I only partially succeeded, for while the uterus became much more mobile, there still remained a swelling or tumor on either side of it. These tumors had ill-defined borders--were not circumscribed, but elongated and rather cylindrical in form, and fixed to the lateral pelvic walls as well as to the uterus, though not very firmly to either. I now suspected disease of the Fallopian tubes, and probably also of the ovaries. The patient entered my private hospital in February, 1885, when I operated upon the cervix, dissecting away a large quantity of tissue for the purpose of making proper adjustment of the labia and to get rid of the cicatricial tissue; it was not epitheliomatous. I had hoped by this operation to not only restore the cervix to health, but at the same time to induce, by a derivative action, a retrograde metamorphosis in the diseased tissues and organs appended to the uterus. I succeeded in the former, and also in modifying all of the symptoms except the pain in the ovarian regions. This seemed to be made worse, or at least to become more prominent, as the other symptoms were improved. The patient was sent to her home, and advised to rest in the recumbent position for at least a part of every day. Later, when she did not improve, a local treatment, consisting of an application of the tincture of iodine to the fundus of the vagina at intervals of a week, with boro-glyceride tampons almost daily, was renewed. At the same time, counter-irritation, applied to the hypogastrium by means of blistering, was faithfully pursued. But nothing proved of more than temporary avail. She began to lose flesh and to fail in strength. The old fulness at the sides of the uterus, instead of diminishing, had increased. She again entered my private hospital. Under the influence of ether I now determined that the {219} Fallopian tubes were distended to the size of a small sausage, that the ovaries were also enlarged, and that the tubes, ovaries, and ligaments were all adherent to one another by plastic lymph. I now advised laparotomy for the removal of the diseased uterine appendages. The patient very readily assented; indeed, she urged the operation.

A week later I made an incision three inches in length through an abdominal wall fully two inches in thickness, and came upon the omentum, which was very fat. This was adherent by its lower border to the pelvic tissues and organs, so that I was compelled to dissect it off on the right side before I could reach the uterus with my fingers. All the parts--Fallopian tubes, ovaries, broad ligaments, uterus, omentum, and intestines--were so adherent and matted together that it was difficult to differentiate between them. The tubes were greatly distended and contained--the right pus, and the left serum. The fimbriated extremities were glued to the lateral pelvic walls. The ovaries were as large as a good-sized hen's egg, and closely adherent to the posterior surface of the broad ligaments. I dissected with my fingers--two being introduced--until the right tube and ovary were released, when they were drawn to the incision, ligated, and removed. The left ovary and tube were released with still greater difficulty, but I finally succeeded in ligating and removing them.

It will be sufficient to say here that the patient recovered without an untoward symptom, and that she has been entirely free from pain--since her recovery--for the first time within the last nine years.

PROGNOSIS.--A very guarded prognosis should always be given as to the course and termination of a case of pelvic inflammation. The disease may run a very acute course, and result in recovery by resolution or suppuration, or it may become chronic and be indefinitely prolonged. An acute parametritis without complications usually runs its course and ends in recovery in from four to six weeks. But the cases which are acute and uncomplicated are vastly in the minority; certainly this is my experience. The course of the disease, as has been stated above, is often chronic, and requires all the patience and fortitude which can be mustered, both by the patient and physician, to bring about a cure. Generally, the prognosis is good where a rational treatment can be pursued. The tendency of the disease is toward recovery, and comparatively few cases die. It is less favorable in cases occurring just after parturition, and which are probably of septic origin. Where the disease is complicated by peritonitis the prognosis, as to life, becomes less favorable.

TREATMENT.--In the acute form, if the patient is seen during the first stage--_i.e._ before exudation has begun--she must immediately be placed in a warm bed. All sources of excitement must be at once removed, the nervous system quieted, and pain relieved by a full dose of morphia administered hypodermatically. I never give less than a quarter of a grain of the sulphate, and seldom more, but I repeat it within an hour if pain is still severe. If reaction from chill has not yet occurred, it should be hastened by the application of dry heat to the lower extremities in the form of vessels filled with hot water, preferably, while moist heat, in the form of a hot flaxseed poultice or some other convenient vehicle, should be applied to the hypogastrium. Great care must be taken that the moisture from the poultice does not escape and wet the clothing of the patient, for that {220} would not only be a source of great discomfort, but it might also be the means of inducing another chill. The heat and moisture are best retained in the poultice by a covering of waxed paper or oiled silk. At the same time, a hot lemonade, to which may be added a teaspoonful of the sweet spirit of nitre, will often be found useful. According to Emmet, hot water per vaginal injection is a sine quâ non in the treatment of this disease. He says: "It is the only means we possess for aborting an attack of cellulitis, which it will do, if thoroughly employed at the beginning."[3] This is strong language, and doubtless the eminent author feels warranted in its use from his experience with the remedy; but I am sure that I have seen reaction brought about and the disease arrested in the first stage by the plan recommended above, and without the use of hot water by injection. There can be no doubt that the first principle to be carried out in the treatment of this disease is rest--absolute and persistent physical and mental rest. This can be obtained by the use of morphia hypodermically or by opium--administered best by the rectum--and probably by nothing else; certainly by nothing else so well. Hot-water injections are objectionable during the first stage of the disease, because of the fuss and movement of the patient necessarily connected with their administration. Further, I think it is impossible to say of any remedy that it aborted an attack of pelvic inflammation, for the disease cannot be said to be unquestionably established until the stage of exudation has been reached. Indeed, intense pelvic congestion may occur, giving rise to symptoms of the first stage of inflammation, and subside spontaneously.

[Footnote 3: _Prin. and Prac. of Gynæcology_, 3d ed., p. 261.]

When it is found that the disease cannot be arrested in the congestive stage, or when it has already passed into the stage of effusion before the patient is seen--which is often the case--exudation should be facilitated by the exhibition of the proper remedies. Happily, the principle to be followed in the treatment of this stage of the disease is the same as that of the first stage--viz. rest, relief of pain, and the local application of heat and moisture, with the addition now of counter-irritation. The first and second are to be obtained by the use of opium. The patient must not be allowed to suffer pain, and immunity can only be secured by the free use of the remedy. This drug is of more value in controlling the heart's action and quieting reflex irritability than all the others combined. The patient should be kept under its influence as long as pain lasts. I usually order twelve suppositories, as follows:

Rx. Ext. opii aq., gr. xij;
Ol. theobromæ, q. s.;
M. et ft. supposit., No. xij.

Sig. One to be placed in the rectum every two hours if necessary to quiet pain.

But we should not wait for the rather slow action of the opium administered in this way. It is best to begin with the administration of morphia hypodermically, as stated above, repeating it until the desired result is secured. It is then not difficult to keep up its influence by the use of the suppositories. If the suppositories cannot be obtained, the tincture of opium may be administered by injection into the rectum. The opium should not be given by the mouth where it can be avoided, as it is more apt to interfere with the appetite and digestion when thus {221} administered. The proper action of the skin and kidneys should be maintained by the administration of the liquor ammoniæ acetatis in dessertspoonful doses. Irritability of the bladder is often a troublesome symptom during the progress of the disease, and is best relieved, in my experience, by the following formula, which combines a diaphoretic and diuretic as well as an antispasmodic:

Rx. Tr. belladonnæ, fluidrachm j;
Sodii bicarbonatis, drachm iij;
Spts. etheris nitrosi, fluidounce j;
Mist. potass. citratis, q. s. ad fluidounce vj.

M.--Sig. Dessertspoonful three or four times a day, or half the quantity oftener. I have also known this combination to relieve the persistent nausea which often accompanies this disease.

As soon as the skin becomes moist the remedy should be given at longer intervals, and if sweating is induced it should be discontinued entirely for the time, as that only serves to weaken the patient.

If the pulse does not beat oftener than 112, and the temperature does not rise above 102°, nothing more in the way of medication will be required. The patient will recover best if not treated too much. On the other hand, should the pulse be strong and rapid and the temperature high, quinine becomes a valuable remedy. It is more efficient when given in large doses at long intervals than when given in small doses at short intervals. If the temperature rises above 102°, it is my rule to administer ten grains and wait six hours, when, if it has not decreased, the quinine is repeated. If, however, the temperature has increased instead of diminishing, twenty grains are given at the second dose, and the effect carefully noted. Should marked cinchonism result, the remedy must be withheld, even though it has had no influence on the temperature. Quinine is said to have the power of so contracting the capillaries as to prevent the migration of the white blood-corpuscles. If this is true, the remedy ought to have great value in modifying or limiting the third or suppurative stage of the disease.

The tincture of aconite-root is also of value in controlling the pulse and lowering the temperature in certain cases. But its use should be limited to those cases of marked sthenic character, for, as a rule, the tendency of the disease is toward depression. It may be given in doses of two to five drops, repeated every two hours until three or four doses are taken, when, sometimes, the pulse will be found to have decreased ten to twenty beats per minute. The remedy should then be withheld until the effect is shown to have passed off by an increase of pulse-rate, when it may be again exhibited; provided always that the heart continues strong and vigorous and that it has shown no sign of weakness. In the latter circumstance the continued use of the medicine would be extremely dangerous. Under any circumstances its use should be limited to the first and early part of the second stage of the disease.

The diet should be carefully attended to, and should be of the most nutritious character, as milk, eggs, beef-essence, etc.

Locally, in addition to the poulticing, but not to the exclusion of it, counter-irritation by means of iodine will be found useful. The whole surface of the hypogastrium should be painted each time the poultice is changed until the skin shows signs of irritation, when it should be {222} discontinued and the poulticing alone kept up. The abdomen must not be exposed longer than is just necessary to remove one and place another poultice, which should be at hand and not in another room. The poultice must never be permitted to become cool on the patient. Turpentine may be used instead of iodine, and if tympanites is a troublesome symptom it will be found valuable. A few drops should be sprinkled over the poultice, or its action may be more quickly obtained by the use of the remedy in the form of the stupe until marked redness of the surface is produced, when the poultice can be resumed. Tympanites is most troublesome when the disease occurs during the puerperal state, and in these cases I regard the turpentine as a most valuable remedy, not only as a counter-irritant, but also when administered internally. It should be given by enema in teaspoonful doses, repeated every six hours until the desired effect is produced. It improves the secretions and allays pain by relieving distension. If the bowels should move as a result of the enemata, it is all the better. If fecal matter occupies the lower bowel, it should be removed under any circumstances.

Blistering, by means of cantharidal collodion or by the pure cantharides spread in the form of a plaster, I regard as the most efficacious counter-irritant; and if the beneficial effects of the remedy could be obtained without the discomforts, and often positive suffering, attending its action, I would probably employ it to the exclusion of all others. But these cannot be obtained. During the acute stage of the disease, when the pulse and temperature are high and the skin hot, the blister should not be used. It is then more likely to produce strangury; if not that, the other sufferings of the patient are at least increased in the pain and burning produced on the surface of the abdomen. This is not compensated for by relief of pelvic pain, for we have relieved this long since by opium. I think blistering should be confined to the chronic stage or form of the disease.

Resolution by reabsorption of the effused product may now terminate the disease; but that is not the rule when the process has once advanced beyond the first or congestive stage. If it is found that suppuration is likely to take place, that the disease is following its natural course, the third stage must be facilitated. The therapeutic plan laid down above will serve to limit the amount of pus-formation and tend to concentrate it to one point for evacuation. The hot fomentations should be continued, as well as the counter-irritation by the iodine. It will probably be observed that the patient has rigors of more or less severity, followed by rise in temperature. These symptoms should be looked upon as an indication of pus-formation. The patient should be examined from time to time by the digital touch per vaginam and by the combined vagino-hypogastric palpation for the purpose of determining the presence of an abscess and its location, so that the proper treatment may be applied and at the proper time.

These examinations must be conducted with the greatest care and gentleness, and the patient protected from undue exposure. When the disease has advanced to the third stage means for the disposition of the pus should be kept constantly in view, and the case treated as one of pelvic abscess.

Treatment of Pelvic Abscess.--Authorities differ widely as to the proper method of disposing of the contents of a pelvic abscess. Some {223} favor a let-alone plan, believing that Nature is competent to relieve herself more effectually and better than art can do; others, equally eminent, believe that the pus should be evacuated when pointing has positively occurred and made the evacuation easy and safe; while others, again, more radical in their views, believe that much can be gained by liberating the pus as soon as it is known to exist, although it may be deep-seated and as yet have shown no tendency toward pointing.