that some very high authorities are strongly opposed to intra-uterine
injections and applications, he would not be just to himself did he not
state that his own experience has been favorable to them. While he once
saw severe and dangerous symptoms follow syringing the cervix with
water to cleanse it of mucus, he never in a single instance saw any
evil effects from intra-uterine injections properly administered, nor
from nitrate of silver à demeure or the application of nitric acid. But
while these measures have often ameliorated cases of menorrhagia where
the endometrium was affected, they have seldom cured, as compared with
the curette. Indeed, the general statement may be made that as of late
years the value of the curette has become more and more recognized,
resort to severe intra-uterine applications has proportionally
diminished. From his experience he is fully prepared to believe with
Courty, that "there are cases of uterine hemorrhage which cannot be
mastered in any other way," and with Siredey, that "the operation cures
in the great majority of cases." It should be noted, in this
connection, that some of the warmest advocates of the instrument
explain its beneficial effects otherwise than by the removal of
fungosities. Thus, Thomas attributes them to "the fracture of tortuous
and distended blood-vessels," and Siredey to "the irritation and
excitation produced by its introduction and action during reflex
contractions."
{208}
INFLAMMATION OF THE PELVIC CELLULAR TISSUE AND PELVIC PERITONEUM.
BY B. F. BAER, M.D.
The subject of inflammation of the tissues surrounding the uterus and
its appendages would be very much simplified, especially for the
general practitioner, by debarring it of all new and superfluous names
and subdivisions, and by treating it on a broad clinical basis. It will
be my aim in this paper to keep that idea constantly in view, rather
than to follow the history and varying pathological views by which it
has been surrounded and complicated.
The importance of this disease is probably greater in its influence on
the health and future usefulness of the woman than any other; and its
causes and prevention, as well as its early recognition and treatment,
should be fully understood by the physicians who are most likely to be
first consulted in the matter, those engaged in general practice. I
feel safe in making the statement that were this so, many of the
chronic cases of almost incurable displacement of the uterus, Fallopian
tubes, and ovaries, resulting from thickened, indurated, and contracted
ligaments, with their distressing symptoms, would never reach the
gynecologist, because they would not then exist. In many cases the
disease would have been prevented; in others it would have been
arrested in its incipiency.
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.
{209} Parametritis.[1]
[Footnote 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.
{210} 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.
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 {211}
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 {212}
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.
It is probable also that the process is sometimes arrested in the
second stage, neither resolution nor suppuration taking place, the
serous portion of the liquor sanguinis being absorbed, the remainder
undergoing a change to plastic lymph, so called, which proceeds to
organization, resulting in persistent induration of the affected parts;
or, instead of being absorbed, the serum may remain encysted within
cavities formed for it by the lymph. This likewise subjects the patient
to the constant menace of a renewal of the inflammation. The late D.
Warren Brickell of New {213} Orleans has called special attention to
what he named the serous form of pelvic inflammation, and which he
thought had been too much neglected.[2] I have met with at least one
well-marked case which supports Brickell's views.
[Footnote 2: "The Treatment of Pelvic Effusions," _Amer. Journ. of the
Med. Sciences_, Philada., April, 1877.]
The usual course, however, of an acute parametritis which has advanced
to suppuration is evacuation of the pus by the most favorable
channel--_i.e._ through the rectum or vagina. If through the latter
organ, the point of perforation is either directly posterior to, or a
little to the side of, the cervix. But if the inflammation be located
in the vesico-uterine space--which is rare, however--the point of
rupture may be anterior to the cervix. Less frequently the bladder is
perforated and the pus discharged with the urine. More rarely the
abscess is discharged through the abdominal wall, groin, or saphenous
opening, and still more rarely through the sacro-ischiatic and
obturator foramina. It may also find exit through the floor of the
pelvis near the anus, and it may rupture into the peritoneal cavity,
but the latter termination is fortunately the least common. This is
probably due to the fact that the slightest irritation and pressure,
under these circumstances especially, result in adhesive inflammation
between the peritoneal surface of the abscess and that of the intestine
with which it may be in contact, thus favoring rupture into the
intestinal tract. Then, rupture into the intestine is conservative and
protective, and the other is not, for should the pus be discharged into
the peritoneal cavity the patient would most likely perish.
When the abscess opens at its most dependent portion, which is the
rule, it is kept thoroughly drained of the pus, and if a single cavity
exists it gradually contracts, and under favorable circumstances soon
disappears, the trouble ending by absorption of the wall of the
abscess. This is the most favorable termination of a parametritis, and
belongs only to the acute form.
When the pus has not been evacuated from the bottom of the sac, or when
there is more than a single cavity and only one is drained, or where
the pus has taken one of the circuitous routes mentioned above, the
disease merges into the chronic form, and may then be indefinitely
prolonged by the formation and evacuation of abscess after abscess,
until the pelvic cellular tissue becomes involved throughout and
riddled by fistulous tracts connecting them.
SYMPTOMATOLOGY.--Pain is probably the first symptom to attract the
attention of the patient, and if the attack is sudden or acute the pain
is usually attended by a chill of more or less severity. The pain may
be so sharp and lancinating as to cause the patient to cry out in
agony, or it may be of a throbbing, aching character. If the former, it
indicates either intense congestion of the vessels and tissues
involved, or that the peritoneum is largely implicated, probably both.
Where the pain is of this character the attack is usually of shorter
duration, since it is soon followed by the second stage, exudation,
when the symptom is at once modified, becoming less acute and
resembling now the pain attending an attack of less severity. Of course
the location of the pain corresponds to the seat of the inflammatory
process. If it is in one or the other broad ligament, the pain is
greater in the right or left iliac regions, most {214} frequently in
the left. Pain is often experienced in the hypogastric and sacral
regions in the beginning of, or preceding, an attack of parametritis,
and it is due to congestion of the endometrium and uterus, from which
the disease is spreading to the looser cellular-tissue spaces in the
ligaments. If, however, sacral pain persists throughout the course of
the disease, or exists in that region chiefly, it indicates that the
inflammation has become general or has invaded the utero-sacral
ligaments. But it would not be correct to estimate the extent of the
disease by the amount of pain complained of, for that symptom depends
so largely upon the temperament of the patient and her station in life
that it is not trustworthy. Some women suffer so much that they become
inured to it or acquire the habit of suffering in silence; others, from
temperament, do not actually experience pain; whilst others, again,
from a love of hardihood, do not complain, although they may be
enduring constant and severe pain. To one of these classes those cases
must belong which are said to pass through an attack of parametritis
without suffering. That cases do rarely present themselves, on account
of mild but persistent symptoms, which are found on examination to
contain a large pelvic exudation, I can attest; but I have so
constantly found on careful questioning that the usual symptoms of
pelvic inflammation were present at some time during the course of the
existing illness that I cannot agree with the statement made by some
authors that this disease may develop "without causing any particular
disturbance" (Emmet).
As a rule, the bladder and rectum are reflexly affected, the former
sometimes becoming very irritable, so that there often exists a
constant desire to micturate. Constipation is the rule, though I have
known a severe diarrhoea to accompany the disease, the result, I
thought, of reflex irritation. The stomach also is often
sympathetically affected, nausea, and sometimes vomiting of an
aggravated form, being present.
With a subsidence of the chill the temperature begins to rise, and
continues to increase, with evening exacerbations, until it reaches
102° to 103°, usually its highest point. It may, however, rise suddenly
and reach as high as 104° or even 105°--rarely above the latter point.
The pulse is usually full, and beats from 112 to 120 per minute,
sometimes oftener.