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

by Unknown

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.