remedies the hot-water douche should be used daily. When the hot water
is administered the patient must be in the recumbent position. I am
opposed to indiscriminately advising walking patients to use hot water,
because, as a rule, it is not given as intended--that is, hot and in
large quantity--and the object for which it has been recommended is not
attained. The water is either used at too low a temperature or in too
small a quantity, or both. When administered by the patient herself she
becomes tired of the pumping and of the position which she must assume,
and fails to keep it up during the length of time required for the
injection of the quantity of water usually advised--that is, a gallon
or two--and the constrained squatting position is of itself injurious.
I believe that the long-continued use of hot water is followed by
relaxation of the pelvic organs, and this would constitute another
objection to the indiscriminate recommendation of this measure, for
when it is placed in the patient's hands she is apt to continue its use
for too long a period. The remedy is no doubt most efficacious in the
treatment of these chronic cases of pelvic peritonitis, and great
credit is due Emmet for introducing it to the profession. It should,
however, be administered in accordance with fixed rules and under
certain restrictions, and these I would class as follows: 1, the
patient must always be in the recumbent posture; 2, she must not
administer the injection herself; 3, the water should be at a certain
temperature, which is best determined by the sensations of the patient.
It should be used as hot as can be easily borne, and the temperature
gradually increased during the administration of the injection, for the
patient will be able to bear it at a higher temperature after the
current has been flowing a few minutes than when the application is
first made. I believe that the douche is better than pumping, as by
Davidson's syringe, because the application is more likely to be
thorough and the effect to be maintained longer, for even when the
injection is given by the physician or nurse the hand is apt to become
tired and the application stopped, for a time at least. It is the
continuous application of the remedy which is beneficial. In other
words, the organs should be kept as it were in a hot bath. For use in
my private hospital I have had constructed a tripod five feet high,
with a hook in the centre on which a bucket is easily hung. This bucket
holds two gallons of water, and near the bottom is placed a stopcock,
to which is attached a tube provided with a nozzle and stopcock at its
distal end. The patient is placed on a bed-pan, which is modified after
that devised by Meriman. The nozzle is then introduced into the vagina,
and the stopcock at the bucket turned by the nurse, the water being at
a temperature of at least 110°. The patient can then regulate the flow
herself. The water is allowed to enter the vagina, dilating it and
flowing off slowly, so that the tissues are in a continuous hot bath,
which may be kept up as long as desired--from ten minutes to an
hour--care being taken to see that the proper temperature of the water
is maintained by the addition of a fresh supply from time to time. The
important point is not so much the amount of water as its temperature
and constant contact. If the vagina could once be filled to distension
and the temperature kept up, it would not be necessary to renew the
water, but to keep up the temperature a regular flow of hot water must
be provided for. The rapidity of the flow may be regulated by the
stopcock. The {236} application of this remedy should be made once or
twice a day, depending on its effect upon the patient.
After all tenderness has subsided much may be accomplished by gentle
massage of the pelvic organs. This is best carried out by the
introduction of one or two fingers of the left hand into the vagina,
while the right hand is placed upon the hypogastrium; then the
contracted ligaments, thickened membranes, and fixed uterus, ovaries,
and tubes should be gently manipulated and moved from side to side or
upward and downward, care being taken that the force used is not
sufficient to lacerate adhesions or even to so stretch them as to cause
their irritation. The proper amount of force is best regulated by the
sensation of the patient, and if pain is produced by the manipulation
it should not be persisted in. This massage may at first be employed at
intervals of two or three days, but later it may for a time be used
almost daily, and it will almost invariably be found that the organs
gradually become more mobile--that the adhesions become attenuated, and
in many cases finally absorbed. On the other hand, adhesions of such
size and strength may exist that many months may be required to produce
any marked effect, and in some cases the adhesions may be of such a
character as to be permanently organized and almost incurably fixed.
I have also found the stretching of the fundus of the vagina by firmly
packing it with absorbent cotton, sometimes repeated almost daily or at
intervals of two, three, or four days, of great benefit in stretching
the adhesions and promoting their absorption. Sometimes, where
adhesions are persistent, the use of the rubber colpeurynter distended
with hot water is of value.
Where there is a foreign body, as a tumor, fixed posteriorly to the
uterus, or where the uterus is fixed in a retroflexed position, the
patient may be placed in the knee-chest position, Sims's speculum
introduced, and the vagina packed with cotton while the patient is in
that posture; or, instead, the vagina may be simply distended with air.
The air may be admitted by the introduction of Campbell's glass tube or
by the separation of the walls of the vagina with the fingers, which
may be done by the patient herself. These measures are often of decided
benefit.
I wish to repeat what has already been stated, that the treatment of
chronic perimetritis, to be carried out successfully, requires that the
patient should be in bed and placed under such circumstances and
surroundings that the physician may be enabled to pursue personally the
plan of treatment. Of course much will be gained if he is aided by a
trained nurse. This in many cases involves the removal of the patient
from the cares of her home.
Advantage may often be derived from the application of small blisters
to the hypogastric and iliac regions, the counter-irritation being kept
up almost continuously for two weeks at a time. The blisters should not
be larger than two inches square, and should be moved from place to
place; for instance, one blister may be placed on the hypogastrium, and
before this has healed a second should be placed one side of it. This
should be kept up for two weeks at a time, or until four or five
blisters have been applied, when, if benefit is to follow, it will be
apparent.
When the organs which are agglutinated to one another become more
mobile, and the thickened membranes more flaccid, much benefit {237}
sometimes results from the application of a pessary if a displacement
of the uterus, ovaries, or tubes exists and persists; but before the
use of this instrument is thought of, it must be positively ascertained
that no tenderness remains as a result of the inflammatory process; the
inflammation must have entirely subsided, the effects alone remaining.
It is sometimes advised that an instrument large enough to constantly
stretch and over-stretch the false membranes and adhesions is
advisable. It has also been recommended to over-stretch these adhesions
by manipulation. Of the two, I much prefer the latter method; that is,
stretching by manipulation rather than by continuously acting upon them
by means of a pessary large enough to stretch the vagina and through it
the adhesions. In stretching by manipulation, with the patient under
ether, you have your own sense of touch to guide you, and the action of
your efforts ceases with the cessation of the manipulation, while that
carried out by means of a pessary is continuous and may result in great
harm from irritation, if not from ulceration of the vaginal surface
from pressure; or it may result in rupture of the adhesions. If a
pessary is adjusted, it should be used, not for the purpose of
over-stretching adhesions, but simply for its stimulating effect on the
pelvic circulation, or as a support to the pelvic circulation rather
than as a support to the uterus. A larger instrument should not be used
than one which will occupy the vagina without stretching it--simply
unfold any doubling up which may have resulted from retroversion or
prolapse of the uterus--and its action should be carefully watched. It
should be learned, not from the sensation of the patient, but from
actual examination, that it is not making undue pressure; this
examination should be made daily at first, and afterward at longer
intervals. The use of the pessary should be discontinued as soon as
possible. This statement should be qualified by saying that the words
as soon as possible mean when all symptoms have subsided, and the
uterus and other organs are maintaining a normal or nearly normal
position, or when the pessary seems to have ceased to be of value. It
may then be removed on trial.
There is a method of using the pessary, in which it is advised that the
instrument shall be large enough to span the angle of flexion which may
exist, for the purpose of making pressure on the fundus of the uterus,
which is incarcerated in the cul-de-sac of Douglas by adhesions between
its peritoneal surface and that lining the sac. This I believe to be a
bad principle, for an instrument long enough to do this must either
take its point of support against the pubic arch or from an external
attachment--a principle of using the pessary which should be most
emphatically condemned.
The above treatment should be carried out with the patient in bed, if
possible, during which time general measures for the improvement of the
muscular and nervous system should also be employed. The application of
electricity to the thickened peritoneum and adhesions is another
measure which should not be allowed to pass without comment. Much good
may be done by the daily application of faradism, with one electrode in
the vagina and the other on the hypogastrium, and continued for from
fifteen to thirty minutes. I have thought that in some cases great
benefit followed this application. Galvanism is also of service, and by
some is thought to be of more value than the faradic current.
{238} The time for getting up should be determined by the results of
treatment; usually a period of from four to six weeks is sufficient to
determine whether or not the treatment at absolute rest is going to be
of benefit. Of course it is not to be understood that cure will follow
in severe and long-standing cases within this period, because if this
hope is entertained disappointment will follow nearly always. What we
hope and expect to attain is rest, both physical and physiological,
during which time local treatment can be carried out with greater
facility and thoroughness and the general condition improved. As a
rule, the ligaments soften, the false membranes become attenuated, and
during the time stated the patient is very much benefited, and
sometimes cured. She should now begin to sit up and to exercise
moderately; the amount of exercise should be regulated by its effect.
If pain follows walking or riding, it should not be persisted in until
such time as exercise can be taken without the production of these
symptoms.
There are no specific remedies for internal administration. The general
medication of the patient should consist in the use of such remedies as
we have learned to depend upon as capable of building up the blood and
nervous system, embracing especially that class of tonics which are
said to have the power of inducing such changes in plastic material as
favors its absorption. To this class belong the chlorides, as the
chloride of arsenic, the chloride of iron, the chloride of ammonium,
and the bichloride of mercury. These remedies should be placed at the
head of the class. The next are the iodides, as the iodide of iron, the
iodide of potassium, and the bromide of potassium. Whether or not these
remedies have the powers ascribed to them is questionable, and their
administration for this purpose must always be, to a certain extent,
empirical. As tonic remedies the administration of iron and the
bichloride of mercury is of course always indicated. Cod-liver oil is
also a remedy of much value in some cases where it can be digested. The
whole plan of treatment should rather be of a local than of a general
character, while at the same time very great importance should be given
to the building up of the general system, without which nothing can be
gained by local treatment. The patient should have a change of scene
and air as soon as practicable. A sojourn at the seaside for a time,
and then in the mountains, will be of great benefit always.
The fact should always be borne in mind by the physician and impressed
upon the patient that a previous attack of perimetritis will serve as a
predisposing and abiding cause for a recurrence of the disease, so that
all exciting causes may be avoided as far as possible.
{239}
PELVIC HÆMATOCELE.
BY T. GAILLARD THOMAS, M.D.
HISTORY.--Prior to the present century the pathological condition which
we are about to investigate had no place in the category of diseases
peculiar to the sexual organs of the female. Very slowly have its
pathogenic features, its etiology, and its importance as a not uncommon
factor in pelvic disorders, assumed a systematic basis, and even now
considerable diversity of opinion exists upon these points. The reasons
for this are not far to seek. In the first place, hæmatocele is a
symptom of an accident occurring in the pelvis and resulting in
hemorrhage; in the second, the source of the flow which creates the
hæmatoma or tumor of blood cannot ordinarily be recognized by any
diagnostic measures known to science; and in the third, death rarely
occurring from the accident and as a direct consequence of it, autopsic
evidence is wanting upon which to base accurate and scientific data.
Although these statements are undoubtedly true, it may nevertheless be
asserted with confidence that we are to-day no longer in the dark as to
the general pathology of this interesting disorder, and that we are in
position to map out a plan of treatment which meets the indications
which present themselves in an intelligent and reliable manner. There
are, however, several sources of hemorrhage which result in pelvic
hæmatocele, and it is highly probable that the day will never come when
that one which has created the accident can be ascertained with
certainty. But while such accuracy of diagnosis would be gratifying to
the ambition of the modern diagnostician, neither the prognosis nor
treatment of the disorder would be influenced by it.
Long before our day practitioners had recognized by touch the
occasional presence of tumors, more or less marked by fluctuation,
which occupied the pouch of Douglas, and by their mechanical influence
pushed the uterus out of its normal place; but it was not until the
early part of our century that it was discovered that these tumors were
sometimes, and that not rarely, composed entirely of coagulated blood;
and, curious though it may appear, it was not until the year 1850 that
pelvic hæmatocele became a well-recognized disorder.
As early as 1737, Ruysch of Amsterdam appears to have come to the verge
of discovering it, but it was left for Récamier, to whom gynecology
owes so much besides, to make it known when in 1831 he opened a
post-uterine tumor, gave vent to a large accumulation of coagulated
blood, and described the case in the _Lancette Française_ for that
year. In 1850 the {240} subject attracted the attention of Nélaton,
became a recognized pathological condition, and has since received a
great deal of attention in all the civilized countries of the world.
DEFINITION AND SYNONYMS.--Pelvic hæmatocele--which has likewise
received the names of retro-uterine hæmatocele and uterine
hæmatoma--may be defined as an effusion of blood into the pelvic cavity
of the female, either into or under the peritoneum. Some authors have
limited this definition to blood escaping from utero-ovarian vessels
and to blood enclosed either by anatomical structures or by
previously-existing inflammatory products. I do not adopt these
restrictions, because their assumption appears to me to be unwarranted
and the validity of the reasons given for their adoption more than
doubtful. The location of the blood-mass differs widely in different
cases: sometimes, and usually, it is behind the uterus--high up when
obliteration of Douglas's pouch has occurred, low down and near to the
perineum where such obliteration has not occurred; at other times it
exists both behind and in front of the uterus; and at others still, in
front of the uterus alone, adhesions preventing its percolation to the
posterior parts of the pelvis.
FREQUENCY.--It may be said, in general terms, that this affection is by
no means rare, every one of large experience in gynecology meeting
necessarily with a large number of cases of it. But no reliable
statistics of its frequency have been collected up to the present time.
Olshausen of Halle declares that in 1145 gynecological cases he saw 34
hæmatoceles; Beigel in 2000 cases found 38; Schroeder, 7 in 1000; and
Seiffert of Prague reports 66 seen in 1272 cases of female pelvic
diseases. Barnes says that in ten years' practice he met with 53 cases,
and in twenty years Tilt has seen but 12.
Without doubt, the validity of the statistics of this disorder is
vitiated by erroneous diagnosis, as is the case with all affections
which generally end in recovery. Here cases of cellulitis, pelvic
peritonitis, imprisoned cysts, etc. offer prolific sources of error, as
I can aver from the results of my own experience.
PATHOLOGY.--It is a fact, thoroughly proved by physiological
experiment, that blood injected into serous cavities very soon encysts
itself by the enveloping influence of lymph which is poured over it,
forming false membranes, or, as the French term them, néo-membranes.
The clot, once formed, clings to the serous membrane in contact with
it, and soon becomes roofed over by lymph, which, according to Vulpian,
begins to show traces of organization as early as the end of
twenty-four hours. Should the effused blood be poor in fibrin, the
coagulation and encysting do not occur, a rapid absorption taking the
place of these processes.
Pelvic hæmatocele consists, as has been already stated, in the
collection of a mass of blood in the pelvis, either above or below its
roof, without reference to the source of the flow. Such a flow
ordinarily occurs from one of the three following sources: first,
rupture of vessels in the pelvis; second, reflux of blood from the
uterus or tubes; third, transudation of blood in consequence of
dyscrasia or pelvic peritonitis.
From this it becomes evident that hæmatocele is not a disease, but a
symptom which marks a number of different pathological conditions of
quite various significance. As, however, we cannot discover the
original accident or pathological condition, we are forced to
compromise with {241} taking its most prominent sign as the exponent of
a state which is beyond the powers of diagnosis.
Autopsic evidence has revealed the following as the special and most
frequent sources of the hemorrhage:
1st. Rupture of blood-vessels in the pelvis:
Utero-ovarian;
Varicose veins of broad ligaments;
Vessels of extra-uterine ovisac.
2d. Rupture of pelvic viscera:
Ovaries;
Fallopian tubes;
Uterus.
3d. Reflux of blood from the uterus:
Menstrual blood.
4th. Transudation from blood-vessels:
Purpura;
Scorbutus;
Chlorosis;
Hemorrhagic peritonitis.
It is then clear that the mere presence of a large clot of blood in the
pelvis, apart from general symptoms, is a matter of very doubtful
significance, since on the one hand it may be the result of a mere
regurgitation of menstrual blood due to imperviousness of the cervical
or tubal canal, or on the other of the rupture of a Fallopian tube
which has become the nidus of an extra-uterine foetus.
Whatever be the source of the blood which escapes, it coagulates,
unless very poor in fibrin, either in the most dependent part of the
peritoneum or in the pelvic areolar tissue beneath it. Here the watery
portions of the mass are gradually absorbed, leaving a hard, small
tumor remaining; or, suppurative action being excited, the hard mass is
softened down and discharged into the rectum, vagina, bladder, or
peritoneum as a grumous material somewhat resembling currant-jelly in
appearance.
CAUSES.--These must be divided into predisposing and exciting, for it
is rare to meet with the disease in a woman who has previously been in
perfect health. The predisposing causes which can be cited with
confidence are--the period of ovarian activity (fifteen to forty-five
years); disordered blood-state, plethora or anæmia; the menstrual
epoch; chronic ovarian or tubal disease; pelvic peritonitis; and the
hemorrhagic diathesis. The exciting causes have been found to be sudden
checking of the menstrual flow; blows or falls; excessive or
intemperate coition; obstruction of cervical canal; obstruction of
Fallopian tubes; violent efforts; and ectopic gestation.
VARIETIES.--The two great classes of the affection are the peritoneal
and the subperitoneal. In the former the blood collects in the
peritoneal cavity and becomes encysted there; in the latter it collects
in the cellular tissue beneath the peritoneum, and there forms a solid
mass.
Some authors have opposed the consideration of these two varieties
under the same head; among them, Aran, Bernutz, and Voisin. But from a
clinical standpoint such a consideration appears to me to be valid. Not
only have distinct instances of subperitoneal hæmatocele been recorded
by such observers as Barnes, Simpson, Olshausen, and Tuckwell, but
{242} cases have been met with in which the subperitoneal variety has
ruptured the peritoneal roof of the pelvis, and thus broken down the
theoretical barrier which pathologists have been inclined to establish
between the two varieties.
Of the two varieties, there can be no doubt that the peritoneal is that
which presents itself the more frequently. In 41 autopsies Tuckwell
found the tumor to be peritoneal in 38.
SYMPTOMS.--As a rule, long before the occurrence of pelvic hemorrhage
the patient will have complained of more or less decided symptoms of
disease, or at least of disorder, of the genital system. The symptoms
which mark blood-dyscrasia or pelvic peritonitis or menstrual
irregularity will probably have attracted attention.
When the accident occurs the gravity of the symptoms will depend in
great degree upon the character of the lesion which has taken place.
Sometimes the blood-accumulation takes place so insidiously that the
existence of the tumor created by coagulation takes the practitioner by
surprise. At other times what Barnes has called a cataclysm occurs, and
in a few hours puts the unfortunate patient beyond the sphere of hope
or the resources of art.
In portraying the symptoms of this affection a writer can therefore
merely approximate the truth, satisfying himself with the description
of a case of ordinary severity, avoiding the description of cases in
either extreme, and guarding the reader against supposing that all
attacks give the same intensity of symptoms.
Most prominent among the immediate symptoms are--severe and sudden
pelvic pain; pallor, faintness, and coldness of the extremities; a
sense of exhaustion; nausea and vomiting; metrorrhagia; uterine
tenesmus; enlargement of the abdomen; interference with the bladder and
rectum; small and rapid pulse; subnormal temperature.
These are the symptoms of invasion, those which may be termed
immediate, and which depend upon loss of blood and a sudden traumatic
influence exerted upon living tissues. Very soon, generally within
forty-eight hours, a reaction occurs which is sometimes slight, and at
other times decided. The secondary symptoms are usually the following:
tendency to chilliness; constipation; suppression of urine; tympanites;
high temperature; rapid pulse; and tenderness over abdomen.
These symptoms are due to a combination of two causes--loss of vital
fluid and the invasion of the peritoneum or pelvic areolar tissue by a
mass of blood which becomes coagulated and irritant, on the one hand,
and inflammatory processes resulting from such invasion on the other.
Half of them might be produced by metrorrhagia, and half by sudden and
complete retroversion; but a union of the whole will point toward
hæmatocele and prompt a physical examination.
PHYSICAL SIGNS.--A tumor will be felt by vaginal touch, usually, though
not always, posterior to the uterus and vagina, and partially occluding
the latter. This will, if the examination be made very early, be found
to be soft and obscurely fluctuating, but it soon becomes a smooth,
dense, and solid body. The uterus is very generally found pressed
upward and forward, so that the body lies against the abdominal wall
and the cervix is on a level with or a little above the symphysis {243}
pubis. In some rare cases the blood-tumor is anterior to or obliquely
to one side of the uterus, but these are very rare.