hypogastric region; the thighs are also flexed upon the abdomen to
protect the parts from pressure and to relieve the abdominal muscles
from tension. But when these symptoms are marked it may be confidently
concluded that the peritoneum is extensively involved.
Within a few days to a week from the initial symptoms the stage of
effusion is probably completed or well advanced, when the symptoms are
usually ameliorated. Pain is diminished and the temperature decreased,
and if, happily, resolution begins, the patient may gradually recover
during the succeeding two or three weeks. But, unfortunately, this very
favorable course is not the usual one. Instead of it, the disease often
advances to the third stage, that of suppuration. This stage is very
commonly ushered in and manifested by rigors or chill, followed by a
rise in temperature and an increase in the pulse-rate. There may now be
daily afternoon exacerbations of temperature, followed by sweating,
until the pus is disposed of, usually by evacuation.
PHYSICAL SIGNS.--If an opportunity is afforded for making a vaginal
{215} examination during the first stage, it will be found that the
local temperature is markedly increased, that great tenderness exists,
and that the parts involved are rigid from congestion. A little later
this rigidity or erection subsides, and a bogginess may be discovered
at the point or points where effusion is now taking place. Still later,
a rather firm and, it may be, irregular swelling of variable size and
location can be detected, usually in one of the broad ligaments, and
from the size of a hen's to that of a goose's egg. If the inflammation
has existed on both sides of the uterus, the pelvic roof, so called,
may be found as hard and firm as a board. If pus has formed,
fluctuation may be felt, and later a softening process may be detected,
indicating the point where Nature is attempting to rid herself of the
product of the inflammation.
The uterus is usually displaced by the exudation to an extent depending
upon the size of the swelling, to which it is fixed more or less
firmly. If the effusion has taken place in one of the broad ligaments,
the organ will be displaced to the opposite side, but if the
inflammatory process has extended to the cellular tissue in the
posterior region of the cervix and in the utero-sacral ligaments, the
organ may be displaced forward as well as laterally. If the cellular
space between the bladder and cervix alone be involved in the
inflammation, the resulting effusion may displace the uterus backward,
but the disease is rarely met with in this location. Retroversion of
the uterus frequently complicates parametritis, but in that case the
abnormal position is not necessarily due to displacement by the
exudation. It may have existed previous to the attack.
It must not be forgotten, however, that the symptoms and physical
signs, as described above, apply only to the acute form of the disease,
and that they do not exist in the same degree nor in the same regular
order when the inflammatory process has been subacute, as it often is,
from its commencement. When the disease is subacute from the start, the
patient may be enabled to go about, and even to pursue a laborious
occupation, but not without suffering. There will always be more or
less pain experienced in the affected region, and the temperature and
pulse will be slightly increased. In rare cases the manifestations of
the disease may be so slight or so little complained of that the
physician is surprised to find, on examination, a large exudation in
one or both broad ligaments.
DIFFERENTIAL DIAGNOSIS.--It is of the greatest importance that this
disease should be recognized early, so that prompt measures may be
taken to arrest it if possible, or at least to modify the severity of
its course. Fortunately, as a rule, the subjective symptoms of pelvic
inflammation are so marked that the attention is at once directed
toward seeking for their confirmation by eliciting the physical signs;
and for diagnosis these local manifestations of the inflammatory
process are to be relied upon entirely, as the subjective symptoms of
inflammation of the other tissues and organs of the pelvis somewhat
resemble those of parametritis.
The diseases the local signs of which approach more nearly those of
parametritis are--pelvic hæmatocele, fibrous tumor, the early stage of
extra-uterine pregnancy, the early stage of parovarian and ovarian
cystic degeneration, and perityphlitis.
In pelvic hæmatocele the symptoms occur suddenly, and often with
hemorrhage; there are also constitutional signs of loss of blood, as
pallor and coldness of the surface of the body, and if the hemorrhage
is great {216} failure of the pulse and syncope. The tumor caused by
the escape of blood into the pelvic cavity is generally post-uterine,
distending Douglas's cul-de-sac and crowding the uterus forward toward
the symphysis pubis, while that formed by parametritis is oftenest
located at the side of the uterus. The hæmatocele at first is soft and
compressible, becoming hard within a short time--a few days--as a
result principally of the surrounding wall of lymph which nature throws
out as a protection. The symptoms of parametritis, on the other hand,
are more likely to come on gradually, and to present the pulse- and
temperature-signs of inflammation, while the resulting swelling or
tumor is rigid at first from congestion of the tissues, then hard,
becoming soft later as the process advances to suppuration. Mere
location of the tumor, however, cannot be depended upon; we must be
guided by the history of the case and the special character of the
tumor.
Fibroid tumor is not attended with the usual acute symptoms of
parametritis, such as pain, increase of temperature, and accelerated
pulse; the tumor is hard from the beginning, or at least never soft; it
is circumscribed, usually smooth, and not sensitive to the touch. Its
attachment to the uterus is also different from that of the tumor
caused by parametritis. The former shows a tendency to pedunculation,
while the latter has always a broad surface attachment.
The tumor resulting from the arrest and development of a fecundated
ovum in the Fallopian tube or ovary resembles very much in its
locality, and somewhat in its characteristics, a parametritic tumor;
for usually more or less inflammatory exudation is present in
connection with extra-uterine pregnancy, giving at times a fixity and
hardness to the gestation-sac not unlike that sometimes observed in a
tumor parametritic in origin; besides, there may also be constitutional
signs of an inflammatory action. But the presence of some of the
ordinary signs of pregnancy and a little time will clear up the
difficulty; for as the case progresses the tumor will increase in size
and change in character, while the mammary and other signs of gestation
will develop. In addition, the pain attending tubal pregnancy is never
like that of parametritis: it is more persistent, lancinating, and
cramp-like in character, and is unattended by rise in temperature. Soon
also the placental bruit may be detected, which of course never exists
in parametritis.
The early stage of normal pregnancy is said to have been mistaken for
this disease. I can hardly conceive how this mistake in diagnosis could
be made, although I have met with several cases where the congestion
consequent upon fecundation was so violent as to result in actual
pelvic inflammatory symptoms with subsequent exudation.
The following case, which I saw with H. A. M. Smith of Gloucester,
N. J., markedly illustrates and confirms this opinion: Mrs. B----, æt.
21, had been married five years, but had never conceived. Her catamenia
had always been regular in time, but the flow had been slight in
quantity. In the latter part of November, 1884, or about three months
before I first saw her, she was attacked with severe pain in the
pelvis, accompanied by rise in temperature and accelerated pulse. She
was compelled to go to bed, where she had remained up to the time of
coming under my care. During this time she suffered from great
tenderness over the hypogastrium, some tympanites, and considerable
nausea and vomiting. She {217} did not menstruate in November--the
period was due when she was first attacked with pain--but in December
she had severe uterine tenesmus and a profuse metrorrhagia--symptoms of
abortion. Pregnancy had not been suspected, however, as she had been so
long sterile, and the inflammatory symptoms had been so violent that
the signs of gestation had been masked by them. At the time of my first
visit (March, 1885), there was great tenderness of the hypogastrium
with slight tympanites; nausea and at times vomiting; great nervous
prostration; loss of flesh; menses absent since November, except the
uterine tenesmus and hemorrhage in December, as above stated; and at
each menstrual cycle afterward she had the symptoms of uterine
contraction with a profuse leucorrhoeal discharge, but no hemorrhage.
The mammary glands showed the usual signs of gestation at about the
fourth month; the vagina was purplish; the cervix uteri low down on the
floor of the pelvis, and the mucous membrane around the os
hypertrophied, soft, and abraded. The body of the uterus was anteverted
and symmetrically enlarged to about the size of the organ at the third
month of gestation. The uterus seemed to be fixed--incarcerated within
the pelvic cavity--by an indurated exudation in the lower portion of
the right broad ligament. I diagnosticated pregnancy, and accompanying
parametritis as a result. The treatment consisted in painting the right
side of the fundus of the vagina opposite the base of the broad
ligament with iodine; the application of iodized glycerin on pledgets
of cotton, together with the use of the hot-water douche; internally,
opium enough to relieve pain and an alterative tonic in the form of the
four chlorides, the formula for which will be given at another place.
She began to improve at once, but as she was still threatened with
abortion and the uterus was still incarcerated within the pelvis, ether
was administered for the purpose of attempting to release it. With two
fingers of the left hand in the vagina and the right hand upon the
hypogastrium to exert counter-pressure, gentle manipulation was made
with the view of stretching the adhesions. This resulted in a slight
elevation of the womb, and from this time pregnancy went on to full
term without further trouble.
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 {218} 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 {219}
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 {220} 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.
[Footnote 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:
Rx. Ext. opii aq., gr. xij;
Ol. theobromæ, q. s.;
M. et ft. supposit., No. xij.
Sig. One to be placed in the rectum every two hours if necessary to
quiet pain.
But we should not wait for the rather slow action of the opium
administered in this way. It is best to begin with the administration
of morphia hypodermically, as stated above, repeating it until the
desired result is secured. It is then not difficult to keep up its
influence by the use of the suppositories. If the suppositories cannot
be obtained, the tincture of opium may be administered by injection
into the rectum. The opium should not be given by the mouth where it
can be avoided, as it is more apt to interfere with the appetite and
digestion when thus {221} administered. The proper action of the skin
and kidneys should be maintained by the administration of the liquor
ammoniæ acetatis in dessertspoonful doses. Irritability of the bladder
is often a troublesome symptom during the progress of the disease, and
is best relieved, in my experience, by the following formula, which
combines a diaphoretic and diuretic as well as an antispasmodic:
Rx. Tr. belladonnæ, fluidrachm j;
Sodii bicarbonatis, drachm iij;
Spts. etheris nitrosi, fluidounce j;
Mist. potass. citratis, q. s. ad fluidounce vj.
M.--Sig. Dessertspoonful three or four times a day, or half the
quantity oftener. I have also known this combination to relieve the
persistent nausea which often accompanies this disease.
As soon as the skin becomes moist the remedy should be given at longer
intervals, and if sweating is induced it should be discontinued
entirely for the time, as that only serves to weaken the patient.