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.