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

by Unknown

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: