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

by Unknown

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.