A system of practical medicine. By American authors. Vol. 4

by Unknown

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.