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.
Parametritis.1
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.
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 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 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 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.
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 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 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 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 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 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 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 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.
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 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 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 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.
The same therapeutic principle should guide us in the management of a pelvic abscess that we would unhesitatingly apply in the treatment of an abscess in any other portion of the body. It is a settled law in surgery that if a pus-cavity is evacuated and not allowed to burrow, much tissue may be saved, the duration of the disease shortened, and the prognosis rendered more favorable. I believe that the pus should be liberated promptly as soon as it is certain that an abscess has been formed and can be reached without danger to important structures—emphatically so when the way is being pointed out. True, Nature is competent in some instances to discharge the accumulation, and usually by the least dangerous channel. But it is also true that in many other cases she is not. Instead of taking the shortest, most direct, and safest course to the surface, the pus frequently takes the most indirect route, riddling and destroying the tissues in its track; or it may rupture into the bladder or peritoneal cavity, in the latter case to be followed by death from peritonitis. Evacuation of the pus by artificial means when the way has been shown, if done carefully by aspiration, is attended with almost no danger. Where, on the other hand, the abscess is deeply seated and there is no tendency toward pointing, the question of evacuation becomes one requiring great deliberation; for the dangers of puncture increase as the thickness of the tissues to be traversed in reaching the abscess is greater. But, even though the pus be deeply located, when a positive diagnosis of its presence can be made I still favor early evacuation. Mere exploratory puncture in the hope of finding pus is a most dangerous practice, and should not be thought of in connection with pelvic abscess. Delay, even at the risk of spontaneous rupture, is the proper course until the diagnosis can be rendered positive; for when the abscess is deep-seated the progress of the disease is often slow. Of course the condition of the patient should always be taken into account in deciding the question whether or not to interfere. If signs of septic absorption appear, or evidences of constitutional failure become prominent in spite of the means used for staying the progress of the disease, prompt measures must be taken to get rid of the product of the inflammation. The strongest argument in favor of early operative evacuation of the abscess is the danger that the disease may become chronic when the pus is not promptly discharged. Many cases have occurred in which abscess after abscess had been formed and discharged, until the patient became a mere wreck of her former self, and finally died from septicæmia or exhaustion. This is the result of non-interference. I am so fully convinced of the value and necessity of operative measures in the treatment of pelvic abscess that the following questions at once present themselves to me when called upon to decide in a case where spontaneous evacuation has not already taken place: 1st. When shall the abscess be opened? 2d. Where shall the opening be made? and 3d. How shall the operation be done?
The first of these questions has been answered in a general way by the preceding remarks, and it is only necessary to add here, by way of recapitulation, that the time for opening the abscess will depend upon its location and the condition of the patient. If the pus is near the surface and can be easily and safely reached, whether pointing has occurred or not, it is ripe for evacuation and should be liberated at once, even though the patient be in the best possible condition and show no evidence of deleterious effect from its presence. Nothing whatever can be gained by permitting it to open spontaneously, but much may be lost. If, however, the situation of the abscess be such that it would be necessary to traverse healthy tissues to a considerable extent in order to reach it, and the patient shows no evidence of septic absorption, it would be highly injudicious to attempt to open the abscess: first, because under the circumstances you could not be positively certain that a collection of pus existed; and, secondly, because it is doing no harm. Delay, with careful observation, is now the proper course. Within a few days the apparent abscess tumor may either show decided signs that it is diminishing in size and undergoing resolution, or it may approach the surface, so that evacuation will become safe. On the other hand, should symptoms of blood-poisoning develop and the patient show signs of rapid exhaustion, our attitude must be one of action instead of delay. The pus must then be liberated even at some risk. I still insist, however, that a positive diagnosis must be established, and that the operative measure shall be in no sense exploratory.
2d. Where shall the opening be made? This question is often decided for us by Nature. The puncture, as a rule, should be made where pointing has occurred. If pointing has not occurred, a position from which the abscess can be most easily reached through the vagina or abdominal wall should be selected. The vagina should be given the preference, because the opening would then be at the most dependent portion. The rectum should not be selected as the channel through which to evacuate the pus artificially, although spontaneous discharge into that tube occurs almost as frequently as into the vagina. The patient does not recover as quickly, however, when the abscess opens into the rectum, and more cases of septic poisoning occur from decomposition of the pus as a result of the entrance of air and fecal matter into the abscess-cavity. Further, it may become necessary to keep the opening patulous and to wash out the cavity of the abscess. This could not be done properly if the opening were in the rectum. I believe it to be the best practice to open from the vagina rather than from the rectum, even at greater risk to intervening structures, because it may greatly facilitate the after-management of the case.
If the tumor should be located high up in the iliac fossa or in the hypogastrium, the point of election for opening must be somewhere on the abdominal surface in the region of the abscess.
3d. How shall the operation be done? The opening of a pelvic abscess should never be regarded as a simple operation. As much care and deliberation should be taken in the selection of the proper method of evacuation of the pus, and in the operation itself, as was previously given to the diagnosis of its presence. Always begin with the administration of an anæsthetic. This not only protects the patient from unnecessary mental agitation and physical pain, but it better enables the physician to confirm his previous opinion of the case, as well as to be more deliberate in the election of the point of puncture. With the patient in the dorsal position, if it be determined that the pus is contained in a single cavity, and there be no evidence of its decomposition, shown by the absence of symptoms of systemic poisoning, it should be liberated by aspiration. By this means a smaller puncture will be required and the entrance of atmospheric air prevented. If, happily, the operation has been performed early, before the formation of the so-called pyogenic membrane, or at least before sinuous tracts have resulted from burrowing, the abscess-cavity may then collapse and disappear. But should the patient not improve after the pus has been removed, or should the cavity again fill up, it is probable either that there is another pus-cavity, which had not been reached by the trocar, or that there has been developed on the internal surface of the sac an unhealthy fungous, granular condition. Under these circumstances a free incision should be made into the cavity of the abscess, so that a drainage-tube may be introduced and the cavity washed out by an antiseptic fluid. The opening should then be kept patulous, so that healing can take place from the bottom of the sac. It may become necessary to introduce a finger and scrape away with the nail the fungosites from the wall of the sac. But great care must be used in this manipulation, as well as in making the incision, for there is danger of wounding large blood-vessels and of rupturing the wall of the sac. If the cavity be now kept pure by daily injections of a 1:1000 solution of the bichloride of mercury or of a 2½-5 per cent. solution of carbolic acid, its surface may become healthy, the secretion diminish, and the sac close up.
The best method of washing out the cavity is by the fountain syringe, to which a long double canula can be attached; or, probably better, the syphon. It would be unsafe to force water into the sac.
It is well for the patient if the situation of the abscess be such as to render its evacuation through the vagina feasible, for then the opening is made at the most dependent portion, and consequently drainage is more easily and thoroughly accomplished; but, unfortunately, the location of the tumor may be so high up as to compel the removal of the pus through the abdominal wall.
Almost the same rules as to the selection of the method of operating and of the election of the point for puncture or incision will apply here as in the operation through the vagina, provided pointing has taken place. I am less favorable to aspiration, however, when the puncture must be made through the walls of the abdomen—first, because reaccumulation is almost certain to take place; and, second, because there is danger of leakage of pus into the peritoneal cavity, since it is difficult by this means to thoroughly empty the sac, and impossible to wash it out and keep it drained.
If pointing has occurred, a free incision should be made at once and the cavity thoroughly emptied, and, if necessary, washed out. The opening must not be permitted to close until the cavity has healed from the bottom.
Where pointing has not occurred and the abscess is so deeply seated that it cannot be safely reached from the vagina, and does not distend the abdominal walls, I would urge greater delay, in the hope that it may approach the surface more nearly. If, however, the condition of the patient be such as to demand immediate action, the operation of laparotomy should be selected as the more thorough and less dangerous method of releasing the pus and of after-treating the abscess.
An incision two inches in length should be made through the linea alba, midway between the umbilicus and pubes, and, after all bleeding is stanched, the peritoneal cavity opened. The index finger should then be passed in and the surface of the abscess-wall explored. It will be a fortunate circumstance if the sac be found adherent to the peritoneal surface, where the incision is made, for it can then be opened without entering the peritoneal cavity. To prevent the escape of pus into this cavity the sac should now be evacuated with great care. For this purpose the aspirator is well adapted, but a small trocar, to which a few feet of rubber tubing has been previously attached, through which to conduct the pus into a convenient receptacle, will answer almost as well. The opening in the sac should next be slightly enlarged by an incision (not torn); it should then be included in the sutures, which are now placed to close the abdominal wound. After the sutures have been introduced the pus-cavity should be washed out with the bichloride or carbolic-acid solution, and a glass drainage-tube placed in the lower angle of the incision, when the edges can be brought together and adjusted around it.
The after-treatment required will be the same as if the opening had been made through the vagina.
The sac must be made to close from the bottom. It may become necessary to stimulate the surface by the injection of a weak solution of nitrate of silver, four to eight grains to the ounce of distilled water, or with the tincture of iodine, one part to four of water.
Cases are sometimes met with in which the pus has burrowed and formed sinuous tracts which are difficult to reach and drain. It may then be necessary to make a counter-opening in the vagina after first cutting through the abdominal wall. These are usually old, neglected, chronic cases, in which the abscess has discharged spontaneously into the bowel too high up to be properly emptied, or which have opened into the bladder or somewhere on the abdominal wall, or possibly taken one of the circuitous routes alluded to under the head of Pathology.
No fixed rule can be set down for the management of these grave cases. Each one must be treated on its individual merits. A ripe experience and judgment are necessary here to decide whether it is best to operate or to pursue a course of masterly inactivity, depending upon the use of hygienic and tonic remedies and time to bring about a cure. I have known instances where patients have recovered spontaneously after having been reduced to the lowest extremity. I have also known others who have died soon after submitting to operative interference. Some of the spontaneous recoveries, however, are only apparent, for the old sinuses often reopen and discharge pus as before, or the pus may be discharged at some new and remote point, the patient finally succumbing to the ravages of a disease from which she flattered herself she had escaped.
The most careful attention must be given to the hygienic surroundings of the patient, the diet liberal and of the most nutritious character. The appetite should be sharpened by the administration of the bitter tonics, the best of which is probably the old tincture of bark (Huxham's). Quinine should be given in doses sufficient to control the temperature when necessary, and for its tonic properties. The blood should be improved by the exhibition of iron, arsenic, and the bichloride of mercury in the form of the mixture of the four chlorides, first used, I believe, by Tilt of London. There can be no doubt as to the value of the combination in cases of plastic exudations. The following is the formula which I am in the habit of using:
| Rx. | Hydrarg. chloridi corrosivi, | gr. j; |
| Liq. arsenici chloridi, | fluidrachm j; | |
| Tr. ferri chloridi, Acid. muriatici diluti, aa. | fluidrachm iv; | |
| Syr. simplici, | fluidounce ij; | |
| Aquæ, q. s. ad | fluidounce vi. |
M.—Sig. Dessertspoonful, well diluted, after meals.
The dose of the arsenic and bichloride of mercury can be increased, after it is found that the mixture does not disagree with the stomach, to six drops of the former and a sixteenth to a twelfth of a grain of the latter. The effect of the medicine must be carefully watched, however. After the remedy has been taken two weeks it should be discontinued and some other form of tonic substituted for a week or two. The syrup of the iodide of iron, or the iodide of iron in pill form, will serve well as the substitute. If the patient should tire of the above or the remedies should not agree, some other form of tonic must be given. I have found the following an excellent tonic pill:
| Rx. | Strychniæ sulphatis, | gr. j; |
| Acidi arseniosi, | gr. j; | |
| Quininæ sulphatis, | gr. xlviii; | |
| Ferri sulphatis, | gr. xlviii; | |
| Ext. hyoscyami, | gr. xij; | |
| Ext. gentianæ, | q. s. |
M. et ft. pil. No. xlviii.—Sig. One to two pills after each meal.
As soon as practicable the patient should have a change of air and scene.
Perimetritis.
Having treated the subject of inflammation of the pelvic tissues generally, in the acute form, under the head of Parametritis, with sufficient fulness to answer the purposes of the practical physician, whether the disease dominate the connective tissue or the peritoneum covering it, I shall, under the head of Perimetritis, consider the subject in its chronic aspect principally.
DEFINITION AND SYNONYMS.—I have defined parametritis to be 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 cannot more clearly or more simply define perimetritis than by stating that it means an inflammation of the peritoneum which serves as a covering and boundary-line for the connective-tissue spaces involved in parametritis. As the term parametritis is used to conveniently express the idea of the existence of an inflammation in the connective tissue near the uterus, so the term perimetritis conveniently and tersely expresses the idea that the inflammatory process exists around the uterus in the pelvic peritoneum. In the acute form it is difficult to differentiate between them clinically, nor is it necessary, from a therapeutic standpoint, to do so. The term perimetritis is synonymous with pelvic peritonitis.
ETIOLOGY.—All of the causes which have been enumerated as capable of producing parametritis may be included in the etiology of perimetritis. If, however, the great predisposing causes of the former—abortion and injury at parturition—be absent, the woman be non-parous, the inflammation will affect the peritoneum rather than the connective tissue. Parametritis is rare before pregnancy has occurred, except in so far as the connective tissue always becomes more or less involved when the peritoneum covering it is inflamed. Perimetritis, on the other hand, is frequent in the single and sterile woman. But, as a rule, it does not run the same typical acute course. It is usually subacute or chronic from the beginning, and results in the formation of false membranes which bind the pelvic organs to one another.
Perimetritis of the adhesive form may be produced by the pressure and irritation resulting from displacement of the pelvic organs, as retroflexion of the uterus, incarcerated fibroid or ovarian tumor, prolapse of the ovary and Fallopian tube, fecal impaction, and from ill-fitting and improperly-adjusted pessaries. Under these circumstances the disease usually comes on insidiously, with no acute symptoms, and runs a slow course. It may be discovered accidentally when making an examination on account of pelvic pain obscure in character, or when the attention has not been called especially to it by the presence of specific symptoms.
Perimetritis may result from regurgitation of menstrual fluid through a too patulous Fallopian tube. This is most likely to take place when the egress to the flow has been prevented by a flexion of the uterus sharp enough to practically destroy the calibre of the cervical canal, as when the organ has become retroflexed from subinvolution or some other cause of hypertrophy of the body of the organ. It may, however, occur as a result of the intense engorgement which sometimes attends acute suppression of the catamenia. It may occur from disease in the tube itself, as where a collection of pus or serum has been formed and thrown into the peritoneal cavity either from rupture of the tube or discharge through the natural opening at the fimbriated extremity. Or it may result from hemorrhage following the rupture of a Graäfian follicle, especially where the disease of the tube has resulted in the destruction of its calibre or the power of the fimbriæ to grasp the ovary so as to convey the discharge safely to the uterine cavity. Hemorrhage from any other source, as from the rupture of a blood-vessel or of an extra-uterine gestation-sac, usually results in the development of perimetritis.
Coitus is capable of causing perimetritis when the act is awkwardly performed, or where there is a disproportion in the relative sizes of the organs involved, or where the physiological mechanism of copulation is destroyed by displacement of the uterus, free mobility being lost as a result.
According to Noeggerrath,4 a very common cause of perimetritis is what he is pleased to call a latent gonorrhoea in the male. He believes that the disease, once contracted, is probably never entirely eradicated, but that it always exists in a latent form, and that it is capable of producing a specific inflammation of the pelvic peritoneum years after an apparent cure had been effected. It is of course impossible to positively verify this, although he gives some very striking cases in support of his position. That gonorrhoea in the acute form may extend by propagation from a vaginitis through the uterine cavity and Fallopian tubes to the peritoneum, and produce an inflammation of that membrane, is probable. Cases have been met with where a history of specific infection was undoubted, in which an attack of perimetritis followed soon after the initial symptoms and physical signs of gonorrhoea were manifested. But it is quite another thing to believe that the specific poison may remain latent and harmless in the genital system of the male to be transferred years afterward to that of the female.
4 "Latent Gonorrhoea, etc.," Trans. Amer. Gynæc. Soc., vol. i. p. 268.
Tuberculous or carcinomatous disease of the pelvic organs is nearly always complicated by a certain degree of perimetritis.
Perimetritis may result from external injuries, as blows, kicks, and the like; and under the head of traumatic agencies most of the causes which have been enumerated would stand as examples; but under this head I wish also to emphasize the statement that I believe that perimetritis may result from an unwarranted and unnecessary force used on the part of the physician in his efforts to outline and locate the position of the pelvic organs, especially that of the ovaries and tubes. When the latter organs are in their normal position and not enlarged, it is usually impossible to outline them by the bimanual touch, nor is it necessary. When they are diseased the greatest care in manipulation should be used; and it is often best to administer an anæsthetic, so that less force may be necessary to determine their exact condition. The disease may also result from injury inflicted in the medication of the uterine cavity and in the various operations on the uterus. A most prolific cause is induced abortion.
Recurrent perimetritis should be regarded as the result of the persistence of one of the above-mentioned causes. It sometimes recurs with each menstrual period. Such attacks are often associated with dysmenorrhoea of the congestive type.
PATHOLOGY, COURSE, AND TERMINATION.—When the pelvic peritoneum becomes inflamed, and the disease runs through an acute course, the pathology and termination will be much the same as that described under Parametritis, for the connective tissue will then be involved in the process, as well as the peritoneum; not to the same extent, however, as when the disease begins as a cellulitis. The position of the exudation tumor, should one form, will be more directly posterior to the uterus in Douglas's cul-de-sac; it is sometimes larger, and may displace the uterus far forward. This is more especially the case where the disease has advanced to the third stage and resulted in abscess.
In the subacute and chronic forms of the disease the course is usually a slow one. The exudation soon becomes plastic, or is so from the beginning. This leads to the agglutination of the pelvic organs to one another, and finally to the production of organized pseudo-membranes of more or less strength. If the Fallopian tubes and ovaries are displaced, which is frequently the case under these circumstances, they are bound more or less firmly in the abnormal position. The adhesions are sometimes extremely delicate, and embrace the displaced organs as a net. At other times, or later, they may be so large and firm as to be readily felt through the vagina. Again, the false membranes may be broad and ribbon-like, and occupy a position so as to imprison the displaced organs as though elastic bands were stretched from the anterior to the posterior portion of the pelvic brim. When Douglas's cul-de-sac is bridged over and shut off from the abdominal cavity proper, serum or pus, sometimes both, may collect within it and give rise, from its round, fluctuating character and rather insidious formation, to the supposition that it is an incarcerated ovarian cyst; especially so since it may progressively increase in size and attain such dimensions as to distend the abdominal walls. This course of the disease is rare, however.
Under favorable circumstances the course and termination of chronic pelvic inflammation would probably be much the same as where the disease is acute—i.e. it would run its natural course and end in resolution by absorption of the effused product. But, unfortunately, the symptoms of the disease are not violent enough to compel the patient to go to bed and remain at rest, so as to place the organs in the most favorable condition for recovery. The affection comes on so insidiously sometimes that when the patient is finally compelled to seek relief it may be found that extensive adhesions and considerable displacement, if not serious disease—especially of the ovaries and Fallopian tubes—exists. The inflammatory process is progressive, and will continue to be so until its cause shall be rendered inactive by the continuous and increasing severity of the symptoms, which force the sufferer to give up the struggle to remain on her feet and pursue her usual round of duties.
SYMPTOMS.—If the attack is acute the subjective symptoms of perimetritis will differ from those described as belonging to parametritis only in the greater violence of their onset and progress. The pain, which is usually preceded by a chill, is likely to be sudden, sharp, and persistent—sometimes agonizing. The pulse, especially during the first stage of the disease, is small, wiry, and quick, ranging from 120 to 140 beats per minute. But its character is likely to change as the affection progresses, and to become full, as when the connective tissue is the seat of the inflammation. The temperature also reaches a higher point, rising frequently as high as 104°-105°, sometimes even higher.
When the disease is chronic from its commencement, the pain is more obscure, and cannot so certainly be relied upon as a diagnostic sign. True, a sharp pain existing low down in the pelvis in either iliac region—pain persistent in character and coming on rather suddenly—should always direct attention to the probable existence of an inflammatory condition. The pain of chronic pelvic inflammation is not attended with the rise in temperature and acceleration of pulse which have been described as accompanying the acute form of the disease. There is, doubtless, a slight degree of increase in both, but not enough to attract attention as a rule. There may be many reflex symptoms, chief of which are irritability of the bladder and stomach, the latter manifesting itself in nausea and sometimes vomiting.
PHYSICAL SIGNS.—Physical examination may reveal no evidence of exudation or of the presence of an inflammatory condition, and may lead the physician to infer that the attacks are not inflammatory in character, but that they are of a neuralgic nature. As a rule, however, examination will show a thickening or an absence of the usual mobility of the surfaces, and deep pressure may elicit considerable tenderness. On the other hand, the physical signs may be marked, and the surfaces may be felt to be quite thickened and very rigid, so that it will be evident that there is exudation on the surface of the peritoneum. Usually, the vaginal examination reveals a fixation and induration posterior to the uterus. If that organ is retroflexed, it is bound firmly in that position. If the uterus is in its normal position, there will not usually be the same amount of fulness posteriorly. If an ovary and Fallopian tube have been displaced, it will probably be fixed in the post-broad-ligament space or in the cul-de-sac of Douglas. The pelvic roof, so called, may be found as hard and tense as a deal board, as was first described by Doherty. The exudation may be so great as to displace the uterus forward or laterally, and to fix it as though it were surrounded by hardened lymph. This is especially felt in the post-uterine space, gluing the uterus, ovaries, tubes, and broad ligaments together. If there is a small ovarian or fibroid tumor, it may be likewise fixed in this posterior position.
A later examination may show a change in this condition. The exudation material may have been reduced by absorption, or there may have been an increase. If the latter, the disease will probably run an acute course and end by resolution or suppuration—more likely the latter—and practically it will then run the course described under the head of Parametritis.
DIAGNOSIS.—The diagnosis of perimetritis is made with comparative ease. The subjective symptoms are sometimes obscure, but the physical signs are perfectly plain. When there is exudation posterior to the uterus, especially if it has bound the organ in a retroverted position or incarcerated a foreign body, it is almost absolutely certain that agglutination is due to peritoneal exudation. This exudation is, as a rule, not so extensive as that which occurs in parametritis, and if a tumor is present—which is uncommon—its location is different. Where a tumor is present as the result of pelvic inflammation, I think that it may be safely ascribed to connective-tissue inflammation rather than to peritoneal. On the other hand, where there is simply agglutination, and where the effusion seems thin and spread out, the organs and ligaments rigid and thickened, instead of a somewhat circumscribed tumor, the disease may be ascribed to perimetritis rather than to parametritis. Where the condition just described is found there can be no doubt as to the existence of perimetritis.
A small ovarian tumor, abscess of the ovary, pyo-salpinx, fibroid tumor, fecal impaction, and hæmatocele might be mistaken for this disease, but these tumors are, as a rule, more or less circumscribed, while the exudation due to perimetritis is not often so. Perimetritis, however, may coexist with any of the conditions just mentioned. These tumors may be bound to adjacent tissues, forming one large mass, as the result of intercurrent attacks of perimetritis. In such cases the peritoneal inflammation would exist as a complication.
PROGNOSIS.—When the inflammation is acute, or where the peritoneum becomes largely involved, the disease may run a very violent and fatal course. Those cases in which pelvic inflammation is of such severity as to cause death are usually of this character. As a rule, however, the prognosis, so far as life is concerned, is favorable.
The prognosis regarding the restoration of the ligaments and the thickened surfaces to their natural condition, and the restoration of the displaced organs which complicate the disease, will depend upon the extent and duration of the affection and upon the treatment. As a rule, the prognosis is good where the patient has sufficient courage and fortitude to submit to a prolonged course of treatment, with the abstemious habits of life which may be necessary.
TREATMENT.—In order to present systematically the therapeutics of perimetritis it should be divided into the acute and chronic forms, and the treatment of the latter form will necessarily include to a certain degree the management of the complications. All that has been said under the head of the treatment of parametritis will apply to the treatment of acute perimetritis. As the symptoms of acute perimetritis are ushered in with greater violence than where the connective tissue is simply involved, so the remedies for the relief of these symptoms must be more vigorously applied. The patient must be placed at absolute rest, and be kept there, for the favorable termination of the disease will be largely dependent on the faithfulness with which this measure is carried out. The pain, which is usually great and acute in character, must be relieved at once by the administration of morphia subcutaneously in full dose, and the remedy is to be repeated until the pain is under control, when the effect of the drug may be maintained by the administration of opium in the form of suppositories containing one grain of the aqueous extract. As in the treatment of parametritis, so here, I insist upon the administration of the drug by the above method, rather than by the mouth, because nausea and interference with the function of digestion are less likely to follow.
In the peritoneal form of pelvic inflammation the pulse is usually more rapid and the temperature higher than where the connective tissue alone is involved. Both of these symptoms may be controlled by the free administration of opium. If this is not successful, a resort to the tincture of aconite in small and repeated doses will be indicated. If necessary, quinia should be administered. This remedy, however, should not be given unless the temperature remains persistently high; and, as advised under the head of Parametritis, the dose should not be less than ten grains, repeated in from four to six hours if the temperature is not decreased. The action of the tincture of aconite should be carefully watched, and if its administration is not soon followed by a lowering of the pulse-rate, its use should be abandoned.
If the disease is of a marked sthenic character, the local abstraction of blood by the application of leeches to the hypogastrium is often of great benefit, and poulticing should be most faithfully and persistently carried out, together with hot applications to the lower extremities in the form of hot water, as previously directed. I strongly recommend the application of heat to the hypogastrium in preference to cold. If the patient be seen quite early in the first stage of the disease, which is unusual, the application of cold might be more beneficial than heat; but when the process has advanced toward the second stage, that of exudation, the application of heat will facilitate this process, while cold would probably retard it.
By the above plan of treatment—viz. the immediate relief of pain by full and repeated doses of morphia—it is possible to arrest the disease in the first stage, but this is not the rule. It usually advances to the second stage, that of exudation, if it has not already reached this stage before the patient is seen. A vaginal examination may now show the uterus to be fixed, but there may be an entire absence of tumor. Should an exudation tumor exist, it will probably be found posterior to the uterus, crowding that organ forward rather than laterally, as would be the case were the inflammatory process seated in the cellular tissue; or, what is oftener the case, we have mere fixity of the organ, with thickening of the pelvic peritoneum lining Douglas's pouch and the posterior surface of the broad ligaments. Later an exudation tumor will more likely be found. If this is so, it should be inferred that the connective tissue has become largely involved in the process, and it should rather be expected that the disease will pass through the regular course of pelvic inflammation and advance to the third stage, that of suppuration, as though the disease had originally begun as a parametritis. It should then be treated on the general principle laid down for the management of that form of pelvic inflammation. The case should, however, be regarded with greater solicitude as to prognosis where the peritoneum has been largely involved, and the symptoms should be more carefully watched and counteracted by the application of the proper remedies. There is in such cases more danger of the disease spreading and involving the peritoneum generally, and of course becoming an affection of great gravity. When the peritoneum is largely involved, tympanites, as a rule, becomes a troublesome symptom, more especially if the disease has occurred during the puerperal period, and it requires special attention. The remedy which I have learned to rely upon in the treatment of this troublesome complication is turpentine, administered preferably by enema.
Should the disease advance to the suppurative stage, the case then becomes one of pelvic abscess, and should be managed on the principle enunciated for that stage of the disease. (See Treatment of Pelvic Abscess.)
Treatment of Chronic Perimetritis.—When the disease exists in its chronic form, the uterus, ovaries, and Fallopian tubes may be found fixed either in the normal position or in some form of displacement, usually the latter. The peritoneum lining Douglas's pouch, as well as that covering the uterus, broad ligaments, tubes, and ovaries, will be found more or less thickened, or the ovaries and tubes may be prolapsed and retained by false membranes; or the uterus itself may be retroflexed and fixed by adhesion of the peritoneal surfaces lining Douglas's pouch and that covering the uterus; or false membranes may have been formed so as to roof over the pelvis, thereby incarcerating the uterus and its appendages within that cavity. This condition gives rise to pains which are rather diffused throughout the pelvis, at one time affecting the ovarian region in which the disease exists, and at another being experienced low down in the pelvis and radiating along the course of the sacral nerve down the posterior portion of the thigh, always sharp and distressing in character. Where the ovary and tube are involved the pain usually radiates to the groin and anterior portion of the thigh. Examination should be conducted with great care, because, although the uterus and its appendages seem to be fixed firmly, there are often new adhesions forming or weak ones existing which may be easily severed; and this especially applies to manipulation of the ovary and tube, the adhesions of which are, as a rule, not so firm as those fixing the uterus.
The management of these cases must of course be different from that of the acute form of the disease. The patient often suffers from nervous exhaustion, indigestion, and loss of flesh as a result of the long suffering which she has endured during the course of the disease. I believe that here the most efficacious plan of treatment is that which embraces REST as its guiding principle, for the disease probably had its origin in over-exertion and derangement of the proper relations of the organs one to another, as in those cases in which it is developed as a result of prolapse or retroflexion of the uterus or the ovaries, or from the presence of a tumor incarcerated in the pelvis, which displaces and holds in malposition the above organs. It is unquestionably true that where the patient is allowed to exercise and follow her usual avocation the attrition of the inflamed surfaces upon each other will tend to keep up the inflammatory condition. It is my plan, where I can get the consent of the patient, to place her at absolute rest, and begin the treatment by paying strict attention to the evacuation of the bowels, for constipation is one of the most troublesome accompaniments of perimetritis. It often stands in a causative relation, and nearly always as a complication of the disease; and of course first attention should be paid to the relief of this condition.
Strict attention should be paid to the diet. The food should be of the most nutritious character, calculated to improve the digestive organs, and through them to build up the general system.
The Local Treatment.—The local treatment should embrace those remedies which are thought to possess the power of producing absorption of plastic material, either by a counter-irritant or stimulating action. The persistent use of the tincture of iodine, both to the hypogastrium and to the fundus of the vagina opposite the seat of exudation, is of great value. Where the iodine is found to be so irritating to the skin as to make it necessary to discontinue its use, and also for the relief of pain, I have found the following formula very useful:
| Rx. | Tincturæ aconiti, Tincturæ opii, aa. | drachm j; |
| Tincturæ iodinii, | drachm vj. Misce. |
Sig. Poison. To be applied externally as directed.
This may also be applied to the fundus of the vagina instead of the iodine alone, either by a camel's-hair brush or by the cotton-wrapped uterine applicator. The vaginal application of iodine should be made not oftener than once in three days, and sometimes a longer interval is advisable, especially if the remedy is used in a concentrated form. If it is found that irritation or ulceration has been produced, its use must be discontinued for a time, and remedies of a milder form substituted, as, for instance, the application of iodoform and glycerin (one drachm to the ounce), or of glycerin alone on the cotton tamponade.
In the intervals between the application of iodine and the other remedies the hot-water douche should be used daily. When the hot water is administered the patient must be in the recumbent position. I am opposed to indiscriminately advising walking patients to use hot water, because, as a rule, it is not given as intended—that is, hot and in large quantity—and the object for which it has been recommended is not attained. The water is either used at too low a temperature or in too small a quantity, or both. When administered by the patient herself she becomes tired of the pumping and of the position which she must assume, and fails to keep it up during the length of time required for the injection of the quantity of water usually advised—that is, a gallon or two—and the constrained squatting position is of itself injurious. I believe that the long-continued use of hot water is followed by relaxation of the pelvic organs, and this would constitute another objection to the indiscriminate recommendation of this measure, for when it is placed in the patient's hands she is apt to continue its use for too long a period. The remedy is no doubt most efficacious in the treatment of these chronic cases of pelvic peritonitis, and great credit is due Emmet for introducing it to the profession. It should, however, be administered in accordance with fixed rules and under certain restrictions, and these I would class as follows: 1, the patient must always be in the recumbent posture; 2, she must not administer the injection herself; 3, the water should be at a certain temperature, which is best determined by the sensations of the patient. It should be used as hot as can be easily borne, and the temperature gradually increased during the administration of the injection, for the patient will be able to bear it at a higher temperature after the current has been flowing a few minutes than when the application is first made. I believe that the douche is better than pumping, as by Davidson's syringe, because the application is more likely to be thorough and the effect to be maintained longer, for even when the injection is given by the physician or nurse the hand is apt to become tired and the application stopped, for a time at least. It is the continuous application of the remedy which is beneficial. In other words, the organs should be kept as it were in a hot bath. For use in my private hospital I have had constructed a tripod five feet high, with a hook in the centre on which a bucket is easily hung. This bucket holds two gallons of water, and near the bottom is placed a stopcock, to which is attached a tube provided with a nozzle and stopcock at its distal end. The patient is placed on a bed-pan, which is modified after that devised by Meriman. The nozzle is then introduced into the vagina, and the stopcock at the bucket turned by the nurse, the water being at a temperature of at least 110°. The patient can then regulate the flow herself. The water is allowed to enter the vagina, dilating it and flowing off slowly, so that the tissues are in a continuous hot bath, which may be kept up as long as desired—from ten minutes to an hour—care being taken to see that the proper temperature of the water is maintained by the addition of a fresh supply from time to time. The important point is not so much the amount of water as its temperature and constant contact. If the vagina could once be filled to distension and the temperature kept up, it would not be necessary to renew the water, but to keep up the temperature a regular flow of hot water must be provided for. The rapidity of the flow may be regulated by the stopcock. The application of this remedy should be made once or twice a day, depending on its effect upon the patient.
After all tenderness has subsided much may be accomplished by gentle massage of the pelvic organs. This is best carried out by the introduction of one or two fingers of the left hand into the vagina, while the right hand is placed upon the hypogastrium; then the contracted ligaments, thickened membranes, and fixed uterus, ovaries, and tubes should be gently manipulated and moved from side to side or upward and downward, care being taken that the force used is not sufficient to lacerate adhesions or even to so stretch them as to cause their irritation. The proper amount of force is best regulated by the sensation of the patient, and if pain is produced by the manipulation it should not be persisted in. This massage may at first be employed at intervals of two or three days, but later it may for a time be used almost daily, and it will almost invariably be found that the organs gradually become more mobile—that the adhesions become attenuated, and in many cases finally absorbed. On the other hand, adhesions of such size and strength may exist that many months may be required to produce any marked effect, and in some cases the adhesions may be of such a character as to be permanently organized and almost incurably fixed.
I have also found the stretching of the fundus of the vagina by firmly packing it with absorbent cotton, sometimes repeated almost daily or at intervals of two, three, or four days, of great benefit in stretching the adhesions and promoting their absorption. Sometimes, where adhesions are persistent, the use of the rubber colpeurynter distended with hot water is of value.
Where there is a foreign body, as a tumor, fixed posteriorly to the uterus, or where the uterus is fixed in a retroflexed position, the patient may be placed in the knee-chest position, Sims's speculum introduced, and the vagina packed with cotton while the patient is in that posture; or, instead, the vagina may be simply distended with air. The air may be admitted by the introduction of Campbell's glass tube or by the separation of the walls of the vagina with the fingers, which may be done by the patient herself. These measures are often of decided benefit.
I wish to repeat what has already been stated, that the treatment of chronic perimetritis, to be carried out successfully, requires that the patient should be in bed and placed under such circumstances and surroundings that the physician may be enabled to pursue personally the plan of treatment. Of course much will be gained if he is aided by a trained nurse. This in many cases involves the removal of the patient from the cares of her home.
Advantage may often be derived from the application of small blisters to the hypogastric and iliac regions, the counter-irritation being kept up almost continuously for two weeks at a time. The blisters should not be larger than two inches square, and should be moved from place to place; for instance, one blister may be placed on the hypogastrium, and before this has healed a second should be placed one side of it. This should be kept up for two weeks at a time, or until four or five blisters have been applied, when, if benefit is to follow, it will be apparent.
When the organs which are agglutinated to one another become more mobile, and the thickened membranes more flaccid, much benefit sometimes results from the application of a pessary if a displacement of the uterus, ovaries, or tubes exists and persists; but before the use of this instrument is thought of, it must be positively ascertained that no tenderness remains as a result of the inflammatory process; the inflammation must have entirely subsided, the effects alone remaining. It is sometimes advised that an instrument large enough to constantly stretch and over-stretch the false membranes and adhesions is advisable. It has also been recommended to over-stretch these adhesions by manipulation. Of the two, I much prefer the latter method; that is, stretching by manipulation rather than by continuously acting upon them by means of a pessary large enough to stretch the vagina and through it the adhesions. In stretching by manipulation, with the patient under ether, you have your own sense of touch to guide you, and the action of your efforts ceases with the cessation of the manipulation, while that carried out by means of a pessary is continuous and may result in great harm from irritation, if not from ulceration of the vaginal surface from pressure; or it may result in rupture of the adhesions. If a pessary is adjusted, it should be used, not for the purpose of over-stretching adhesions, but simply for its stimulating effect on the pelvic circulation, or as a support to the pelvic circulation rather than as a support to the uterus. A larger instrument should not be used than one which will occupy the vagina without stretching it—simply unfold any doubling up which may have resulted from retroversion or prolapse of the uterus—and its action should be carefully watched. It should be learned, not from the sensation of the patient, but from actual examination, that it is not making undue pressure; this examination should be made daily at first, and afterward at longer intervals. The use of the pessary should be discontinued as soon as possible. This statement should be qualified by saying that the words as soon as possible mean when all symptoms have subsided, and the uterus and other organs are maintaining a normal or nearly normal position, or when the pessary seems to have ceased to be of value. It may then be removed on trial.
There is a method of using the pessary, in which it is advised that the instrument shall be large enough to span the angle of flexion which may exist, for the purpose of making pressure on the fundus of the uterus, which is incarcerated in the cul-de-sac of Douglas by adhesions between its peritoneal surface and that lining the sac. This I believe to be a bad principle, for an instrument long enough to do this must either take its point of support against the pubic arch or from an external attachment—a principle of using the pessary which should be most emphatically condemned.
The above treatment should be carried out with the patient in bed, if possible, during which time general measures for the improvement of the muscular and nervous system should also be employed. The application of electricity to the thickened peritoneum and adhesions is another measure which should not be allowed to pass without comment. Much good may be done by the daily application of faradism, with one electrode in the vagina and the other on the hypogastrium, and continued for from fifteen to thirty minutes. I have thought that in some cases great benefit followed this application. Galvanism is also of service, and by some is thought to be of more value than the faradic current.
The time for getting up should be determined by the results of treatment; usually a period of from four to six weeks is sufficient to determine whether or not the treatment at absolute rest is going to be of benefit. Of course it is not to be understood that cure will follow in severe and long-standing cases within this period, because if this hope is entertained disappointment will follow nearly always. What we hope and expect to attain is rest, both physical and physiological, during which time local treatment can be carried out with greater facility and thoroughness and the general condition improved. As a rule, the ligaments soften, the false membranes become attenuated, and during the time stated the patient is very much benefited, and sometimes cured. She should now begin to sit up and to exercise moderately; the amount of exercise should be regulated by its effect. If pain follows walking or riding, it should not be persisted in until such time as exercise can be taken without the production of these symptoms.
There are no specific remedies for internal administration. The general medication of the patient should consist in the use of such remedies as we have learned to depend upon as capable of building up the blood and nervous system, embracing especially that class of tonics which are said to have the power of inducing such changes in plastic material as favors its absorption. To this class belong the chlorides, as the chloride of arsenic, the chloride of iron, the chloride of ammonium, and the bichloride of mercury. These remedies should be placed at the head of the class. The next are the iodides, as the iodide of iron, the iodide of potassium, and the bromide of potassium. Whether or not these remedies have the powers ascribed to them is questionable, and their administration for this purpose must always be, to a certain extent, empirical. As tonic remedies the administration of iron and the bichloride of mercury is of course always indicated. Cod-liver oil is also a remedy of much value in some cases where it can be digested. The whole plan of treatment should rather be of a local than of a general character, while at the same time very great importance should be given to the building up of the general system, without which nothing can be gained by local treatment. The patient should have a change of scene and air as soon as practicable. A sojourn at the seaside for a time, and then in the mountains, will be of great benefit always.
The fact should always be borne in mind by the physician and impressed upon the patient that a previous attack of perimetritis will serve as a predisposing and abiding cause for a recurrence of the disease, so that all exciting causes may be avoided as far as possible.