not rise above 102°, nothing more in the way of medication will be
required. The patient will recover best if not treated too much. On the
other hand, should the pulse be strong and rapid and the temperature
high, quinine becomes a valuable remedy. It is more efficient when
given in large doses at long intervals than when given in small doses
at short intervals. If the temperature rises above 102°, it is my rule
to administer ten grains and wait six hours, when, if it has not
decreased, the quinine is repeated. If, however, the temperature has
increased instead of diminishing, twenty grains are given at the second
dose, and the effect carefully noted. Should marked cinchonism result,
the remedy must be withheld, even though it has had no influence on the
temperature. Quinine is said to have the power of so contracting the
capillaries as to prevent the migration of the white blood-corpuscles.
If this is true, the remedy ought to have great value in modifying or
limiting the third or suppurative stage of the disease.
The tincture of aconite-root is also of value in controlling the pulse
and lowering the temperature in certain cases. But its use should be
limited to those cases of marked sthenic character, for, as a rule, the
tendency of the disease is toward depression. It may be given in doses
of two to five drops, repeated every two hours until three or four
doses are taken, when, sometimes, the pulse will be found to have
decreased ten to twenty beats per minute. The remedy should then be
withheld until the effect is shown to have passed off by an increase of
pulse-rate, when it may be again exhibited; provided always that the
heart continues strong and vigorous and that it has shown no sign of
weakness. In the latter circumstance the continued use of the medicine
would be extremely dangerous. Under any circumstances its use should be
limited to the first and early part of the second stage of the disease.
The diet should be carefully attended to, and should be of the most
nutritious character, as milk, eggs, beef-essence, etc.
Locally, in addition to the poulticing, but not to the exclusion of it,
counter-irritation by means of iodine will be found useful. The whole
surface of the hypogastrium should be painted each time the poultice is
changed until the skin shows signs of irritation, when it should be
{222} discontinued and the poulticing alone kept up. The abdomen must
not be exposed longer than is just necessary to remove one and place
another poultice, which should be at hand and not in another room. The
poultice must never be permitted to become cool on the patient.
Turpentine may be used instead of iodine, and if tympanites is a
troublesome symptom it will be found valuable. A few drops should be
sprinkled over the poultice, or its action may be more quickly obtained
by the use of the remedy in the form of the stupe until marked redness
of the surface is produced, when the poultice can be resumed.
Tympanites is most troublesome when the disease occurs during the
puerperal state, and in these cases I regard the turpentine as a most
valuable remedy, not only as a counter-irritant, but also when
administered internally. It should be given by enema in teaspoonful
doses, repeated every six hours until the desired effect is produced.
It improves the secretions and allays pain by relieving distension. If
the bowels should move as a result of the enemata, it is all the
better. If fecal matter occupies the lower bowel, it should be removed
under any circumstances.
Blistering, by means of cantharidal collodion or by the pure
cantharides spread in the form of a plaster, I regard as the most
efficacious counter-irritant; and if the beneficial effects of the
remedy could be obtained without the discomforts, and often positive
suffering, attending its action, I would probably employ it to the
exclusion of all others. But these cannot be obtained. During the acute
stage of the disease, when the pulse and temperature are high and the
skin hot, the blister should not be used. It is then more likely to
produce strangury; if not that, the other sufferings of the patient are
at least increased in the pain and burning produced on the surface of
the abdomen. This is not compensated for by relief of pelvic pain, for
we have relieved this long since by opium. I think blistering should be
confined to the chronic stage or form of the disease.
Resolution by reabsorption of the effused product may now terminate the
disease; but that is not the rule when the process has once advanced
beyond the first or congestive stage. If it is found that suppuration
is likely to take place, that the disease is following its natural
course, the third stage must be facilitated. The therapeutic plan laid
down above will serve to limit the amount of pus-formation and tend to
concentrate it to one point for evacuation. The hot fomentations should
be continued, as well as the counter-irritation by the iodine. It will
probably be observed that the patient has rigors of more or less
severity, followed by rise in temperature. These symptoms should be
looked upon as an indication of pus-formation. The patient should be
examined from time to time by the digital touch per vaginam and by the
combined vagino-hypogastric palpation for the purpose of determining
the presence of an abscess and its location, so that the proper
treatment may be applied and at the proper time.
These examinations must be conducted with the greatest care and
gentleness, and the patient protected from undue exposure. When the
disease has advanced to the third stage means for the disposition of
the pus should be kept constantly in view, and the case treated as one
of pelvic abscess.
Treatment of Pelvic Abscess.--Authorities differ widely as to the
proper method of disposing of the contents of a pelvic abscess. Some
{223} favor a let-alone plan, believing that Nature is competent to
relieve herself more effectually and better than art can do; others,
equally eminent, believe that the pus should be evacuated when pointing
has positively occurred and made the evacuation easy and safe; while
others, again, more radical in their views, believe that much can be
gained by liberating the pus as soon as it is known to exist, although
it may be deep-seated and as yet have shown no tendency toward
pointing.
The same therapeutic principle should guide us in the management of a
pelvic abscess that we would unhesitatingly apply in the treatment of
an abscess in any other portion of the body. It is a settled law in
surgery that if a pus-cavity is evacuated and not allowed to burrow,
much tissue may be saved, the duration of the disease shortened, and
the prognosis rendered more favorable. I believe that the pus should be
liberated promptly as soon as it is certain that an abscess has been
formed and can be reached without danger to important
structures--emphatically so when the way is being pointed out. True,
Nature is competent in some instances to discharge the accumulation,
and usually by the least dangerous channel. But it is also true that in
many other cases she is not. Instead of taking the shortest, most
direct, and safest course to the surface, the pus frequently takes the
most indirect route, riddling and destroying the tissues in its track;
or it may rupture into the bladder or peritoneal cavity, in the latter
case to be followed by death from peritonitis. Evacuation of the pus by
artificial means when the way has been shown, if done carefully by
aspiration, is attended with almost no danger. Where, on the other
hand, the abscess is deeply seated and there is no tendency toward
pointing, the question of evacuation becomes one requiring great
deliberation; for the dangers of puncture increase as the thickness of
the tissues to be traversed in reaching the abscess is greater. But,
even though the pus be deeply located, when a positive diagnosis of its
presence can be made I still favor early evacuation. Mere exploratory
puncture in the hope of finding pus is a most dangerous practice, and
should not be thought of in connection with pelvic abscess. Delay, even
at the risk of spontaneous rupture, is the proper course until the
diagnosis can be rendered positive; for when the abscess is deep-seated
the progress of the disease is often slow. Of course the condition of
the patient should always be taken into account in deciding the
question whether or not to interfere. If signs of septic absorption
appear, or evidences of constitutional failure become prominent in
spite of the means used for staying the progress of the disease, prompt
measures must be taken to get rid of the product of the inflammation.
The strongest argument in favor of early operative evacuation of the
abscess is the danger that the disease may become chronic when the pus
is not promptly discharged. Many cases have occurred in which abscess
after abscess had been formed and discharged, until the patient became
a mere wreck of her former self, and finally died from septicæmia or
exhaustion. This is the result of non-interference. I am so fully
convinced of the value and necessity of operative measures in the
treatment of pelvic abscess that the following questions at once
present themselves to me when called upon to decide in a case where
spontaneous evacuation has not already taken place: 1st. When shall the
abscess be opened? 2d. Where shall the opening be made? and 3d. How
shall the operation be done?
{224} The first of these questions has been answered in a general way
by the preceding remarks, and it is only necessary to add here, by way
of recapitulation, that the time for opening the abscess will depend
upon its location and the condition of the patient. If the pus is near
the surface and can be easily and safely reached, whether pointing has
occurred or not, it is ripe for evacuation and should be liberated at
once, even though the patient be in the best possible condition and
show no evidence of deleterious effect from its presence. Nothing
whatever can be gained by permitting it to open spontaneously, but much
may be lost. If, however, the situation of the abscess be such that it
would be necessary to traverse healthy tissues to a considerable extent
in order to reach it, and the patient shows no evidence of septic
absorption, it would be highly injudicious to attempt to open the
abscess: first, because under the circumstances you could not be
positively certain that a collection of pus existed; and, secondly,
because it is doing no harm. Delay, with careful observation, is now
the proper course. Within a few days the apparent abscess tumor may
either show decided signs that it is diminishing in size and undergoing
resolution, or it may approach the surface, so that evacuation will
become safe. On the other hand, should symptoms of blood-poisoning
develop and the patient show signs of rapid exhaustion, our attitude
must be one of action instead of delay. The pus must then be liberated
even at some risk. I still insist, however, that a positive diagnosis
must be established, and that the operative measure shall be in no
sense exploratory.
2d. Where shall the opening be made? This question is often decided for
us by Nature. The puncture, as a rule, should be made where pointing
has occurred. If pointing has not occurred, a position from which the
abscess can be most easily reached through the vagina or abdominal wall
should be selected. The vagina should be given the preference, because
the opening would then be at the most dependent portion. The rectum
should not be selected as the channel through which to evacuate the pus
artificially, although spontaneous discharge into that tube occurs
almost as frequently as into the vagina. The patient does not recover
as quickly, however, when the abscess opens into the rectum, and more
cases of septic poisoning occur from decomposition of the pus as a
result of the entrance of air and fecal matter into the abscess-cavity.
Further, it may become necessary to keep the opening patulous and to
wash out the cavity of the abscess. This could not be done properly if
the opening were in the rectum. I believe it to be the best practice to
open from the vagina rather than from the rectum, even at greater risk
to intervening structures, because it may greatly facilitate the
after-management of the case.
If the tumor should be located high up in the iliac fossa or in the
hypogastrium, the point of election for opening must be somewhere on
the abdominal surface in the region of the abscess.
3d. How shall the operation be done? The opening of a pelvic abscess
should never be regarded as a simple operation. As much care and
deliberation should be taken in the selection of the proper method of
evacuation of the pus, and in the operation itself, as was previously
given to the diagnosis of its presence. Always begin with the
administration of an anæsthetic. This not only protects the patient
from unnecessary mental agitation and physical pain, but it better
enables the {225} physician to confirm his previous opinion of the
case, as well as to be more deliberate in the election of the point of
puncture. With the patient in the dorsal position, if it be determined
that the pus is contained in a single cavity, and there be no evidence
of its decomposition, shown by the absence of symptoms of systemic
poisoning, it should be liberated by aspiration. By this means a
smaller puncture will be required and the entrance of atmospheric air
prevented. If, happily, the operation has been performed early, before
the formation of the so-called pyogenic membrane, or at least before
sinuous tracts have resulted from burrowing, the abscess-cavity may
then collapse and disappear. But should the patient not improve after
the pus has been removed, or should the cavity again fill up, it is
probable either that there is another pus-cavity, which had not been
reached by the trocar, or that there has been developed on the internal
surface of the sac an unhealthy fungous, granular condition. Under
these circumstances a free incision should be made into the cavity of
the abscess, so that a drainage-tube may be introduced and the cavity
washed out by an antiseptic fluid. The opening should then be kept
patulous, so that healing can take place from the bottom of the sac. It
may become necessary to introduce a finger and scrape away with the
nail the fungosites from the wall of the sac. But great care must be
used in this manipulation, as well as in making the incision, for there
is danger of wounding large blood-vessels and of rupturing the wall of
the sac. If the cavity be now kept pure by daily injections of a 1:1000
solution of the bichloride of mercury or of a 2½-5 per cent. solution
of carbolic acid, its surface may become healthy, the secretion
diminish, and the sac close up.
The best method of washing out the cavity is by the fountain syringe,
to which a long double canula can be attached; or, probably better, the
syphon. It would be unsafe to force water into the sac.
It is well for the patient if the situation of the abscess be such as
to render its evacuation through the vagina feasible, for then the
opening is made at the most dependent portion, and consequently
drainage is more easily and thoroughly accomplished; but,
unfortunately, the location of the tumor may be so high up as to compel
the removal of the pus through the abdominal wall.
Almost the same rules as to the selection of the method of operating
and of the election of the point for puncture or incision will apply
here as in the operation through the vagina, provided pointing has
taken place. I am less favorable to aspiration, however, when the
puncture must be made through the walls of the abdomen--first, because
reaccumulation is almost certain to take place; and, second, because
there is danger of leakage of pus into the peritoneal cavity, since it
is difficult by this means to thoroughly empty the sac, and impossible
to wash it out and keep it drained.
If pointing has occurred, a free incision should be made at once and
the cavity thoroughly emptied, and, if necessary, washed out. The
opening must not be permitted to close until the cavity has healed from
the bottom.
Where pointing has not occurred and the abscess is so deeply seated
that it cannot be safely reached from the vagina, and does not distend
the abdominal walls, I would urge greater delay, in the hope that it
may {226} approach the surface more nearly. If, however, the condition
of the patient be such as to demand immediate action, the operation of
laparotomy should be selected as the more thorough and less dangerous
method of releasing the pus and of after-treating the abscess.
An incision two inches in length should be made through the linea alba,
midway between the umbilicus and pubes, and, after all bleeding is
stanched, the peritoneal cavity opened. The index finger should then be
passed in and the surface of the abscess-wall explored. It will be a
fortunate circumstance if the sac be found adherent to the peritoneal
surface, where the incision is made, for it can then be opened without
entering the peritoneal cavity. To prevent the escape of pus into this
cavity the sac should now be evacuated with great care. For this
purpose the aspirator is well adapted, but a small trocar, to which a
few feet of rubber tubing has been previously attached, through which
to conduct the pus into a convenient receptacle, will answer almost as
well. The opening in the sac should next be slightly enlarged by an
incision (not torn); it should then be included in the sutures, which
are now placed to close the abdominal wound. After the sutures have
been introduced the pus-cavity should be washed out with the bichloride
or carbolic-acid solution, and a glass drainage-tube placed in the
lower angle of the incision, when the edges can be brought together and
adjusted around it.
The after-treatment required will be the same as if the opening had
been made through the vagina.
The sac must be made to close from the bottom. It may become necessary
to stimulate the surface by the injection of a weak solution of nitrate
of silver, four to eight grains to the ounce of distilled water, or
with the tincture of iodine, one part to four of water.
Cases are sometimes met with in which the pus has burrowed and formed
sinuous tracts which are difficult to reach and drain. It may then be
necessary to make a counter-opening in the vagina after first cutting
through the abdominal wall. These are usually old, neglected, chronic
cases, in which the abscess has discharged spontaneously into the bowel
too high up to be properly emptied, or which have opened into the
bladder or somewhere on the abdominal wall, or possibly taken one of
the circuitous routes alluded to under the head of Pathology.
No fixed rule can be set down for the management of these grave cases.
Each one must be treated on its individual merits. A ripe experience
and judgment are necessary here to decide whether it is best to operate
or to pursue a course of masterly inactivity, depending upon the use of
hygienic and tonic remedies and time to bring about a cure. I have
known instances where patients have recovered spontaneously after
having been reduced to the lowest extremity. I have also known others
who have died soon after submitting to operative interference. Some of
the spontaneous recoveries, however, are only apparent, for the old
sinuses often reopen and discharge pus as before, or the pus may be
discharged at some new and remote point, the patient finally succumbing
to the ravages of a disease from which she flattered herself she had
escaped.
The most careful attention must be given to the hygienic surroundings
of the patient, the diet liberal and of the most nutritious character.
The appetite should be sharpened by the administration of the bitter
tonics, {227} the best of which is probably the old tincture of bark
(Huxham's). Quinine should be given in doses sufficient to control the
temperature when necessary, and for its tonic properties. The blood
should be improved by the exhibition of iron, arsenic, and the
bichloride of mercury in the form of the mixture of the four chlorides,
first used, I believe, by Tilt of London. There can be no doubt as to
the value of the combination in cases of plastic exudations. The
following is the formula which I am in the habit of using:
Rx. Hydrarg. chloridi corrosivi, gr. j;
Liq. arsenici chloridi, fluidrachm j;
Tr. ferri chloridi,
Acid. muriatici diluti, aa. fluidrachm iv;
Syr. simplici, fluidounce ij;
Aquæ, q. s. ad fluidounce vi.
M.--Sig. Dessertspoonful, well diluted, after meals.
The dose of the arsenic and bichloride of mercury can be increased,
after it is found that the mixture does not disagree with the stomach,
to six drops of the former and a sixteenth to a twelfth of a grain of
the latter. The effect of the medicine must be carefully watched,
however. After the remedy has been taken two weeks it should be
discontinued and some other form of tonic substituted for a week or
two. The syrup of the iodide of iron, or the iodide of iron in pill
form, will serve well as the substitute. If the patient should tire of
the above or the remedies should not agree, some other form of tonic
must be given. I have found the following an excellent tonic pill:
Rx. Strychniæ sulphatis, gr. j;
Acidi arseniosi, gr. j;
Quininæ sulphatis, gr. xlviii;
Ferri sulphatis, gr. xlviii;
Ext. hyoscyami, gr. xij;
Ext. gentianæ, q. s.
M. et ft. pil. No. xlviii.--Sig. One to two pills after each meal.
As soon as practicable the patient should have a change of air and
scene.
Perimetritis.
Having treated the subject of inflammation of the pelvic tissues
generally, in the acute form, under the head of Parametritis, with
sufficient fulness to answer the purposes of the practical physician,
whether the disease dominate the connective tissue or the peritoneum
covering it, I shall, under the head of Perimetritis, consider the
subject in its chronic aspect principally.
DEFINITION AND SYNONYMS.--I have defined parametritis to be 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 cannot more clearly or
more simply define perimetritis than by stating that it means an
inflammation of the peritoneum {228} which serves as a covering and
boundary-line for the connective-tissue spaces involved in
parametritis. As the term parametritis is used to conveniently express
the idea of the existence of an inflammation in the connective tissue
near the uterus, so the term perimetritis conveniently and tersely
expresses the idea that the inflammatory process exists around the
uterus in the pelvic peritoneum. In the acute form it is difficult to
differentiate between them clinically, nor is it necessary, from a
therapeutic standpoint, to do so. The term perimetritis is synonymous
with pelvic peritonitis.
ETIOLOGY.--All of the causes which have been enumerated as capable of
producing parametritis may be included in the etiology of perimetritis.
If, however, the great predisposing causes of the former--abortion and
injury at parturition--be absent, the woman be non-parous, the
inflammation will affect the peritoneum rather than the connective
tissue. Parametritis is rare before pregnancy has occurred, except in
so far as the connective tissue always becomes more or less involved
when the peritoneum covering it is inflamed. Perimetritis, on the other
hand, is frequent in the single and sterile woman. But, as a rule, it
does not run the same typical acute course. It is usually subacute or
chronic from the beginning, and results in the formation of false
membranes which bind the pelvic organs to one another.
Perimetritis of the adhesive form may be produced by the pressure and
irritation resulting from displacement of the pelvic organs, as
retroflexion of the uterus, incarcerated fibroid or ovarian tumor,
prolapse of the ovary and Fallopian tube, fecal impaction, and from
ill-fitting and improperly-adjusted pessaries. Under these
circumstances the disease usually comes on insidiously, with no acute
symptoms, and runs a slow course. It may be discovered accidentally
when making an examination on account of pelvic pain obscure in
character, or when the attention has not been called especially to it
by the presence of specific symptoms.