PELVIC CELLULITIS OR PARAMETRITIS.
THE term _cellular_ was given to this tissue, because under the
microscope it shows large meshes or cell-like cavities, that are also
termed areolæ, hence, the tissue is often called areolar tissue; it is
also called connective tissue, because it combines all the different
organs and structures of the body together. It is very elastic and
contractile, and by the fluid which it contains in its areolæ, motion
of parts on each other is facilitated.
Professor Virchow has applied to it, in the region of the womb or
pelvis, the term _parametric_ tissue, from the Greek prefix _para_,
beside, and the Latin _metra_, the womb, signifying the tissue near and
around the womb, from which the Germans derive _parametritis_, instead
of the English, who employ _pelvic-cellulitis_, each meaning one and
the same thing, namely, inflammation of the cellular or connective
tissue in the pelvis or around the womb.
The female pelvic organs have interspaces between the bladder, vagina
and uterus in front, and the uterus, vagina and rectum behind, also
on both sides, between the womb, ovaries, and the folds of the broad
ligaments, and lastly, between these organs and the walls of the pelvic
cavity are interspaces. These interspaces are filled in or padded out
by loose cellular tissue. M. Nonat, a celebrated French authority, has
described this in a beautiful figure, by saying that “the organs of
reproduction float in an atmosphere of cellular tissue.” This is indeed
so, and a consideration of an inflammatory condition of this structure,
is to conclude the inquiry into the inflammatory diseases peculiar to
women.
Pelvic cellulitis is one of those diseases for the comprehension
of which we are particularly indebted to the researches of modern
pathologists, who have discovered that infectious germs are the cause
of numerous diseases; pelvic cellulitis is one of these, because it
originates as a secondary result of septic absorption.
The bacteria or putrefactive germs belong to Protophytes—the smallest
and simplest of all plants, some of them are so small that it requires
the highest powers of the microscope to make them visible. Their growth
and multiplication have been experimentally demonstrated by artificial
cultivation, and this now constitutes one of the most interesting
studies of modern pathology.
Pasteur, Lister, Nægle and others, regard the decomposition in
the tissues as a direct result of the vegetation of the bacteria.
“Decomposition and fungus are inseparable; the one ceases when the
other is removed. Processes of this nature set up by bacteria are
best distinguished as _fermentations_.” Professor Ziegler, of the
University of Tuebingen, says: “The healthy organism is always beset
with a multitude of _non-infectious bacteria_. They occupy the natural
cavities accessible from without, and especially the alimentary canal.
They feed on the substances lying in their neighborhood, whether
brought into the body or secreted by the tissues. In so doing they
set up chemical changes in these tissues. While the organs are acting
normally, these fungi work no mischief to the tissues in which they
lie, or to the system generally. The products of decomposition set
up by such non-specific micro-organisms are either harmless or are
conveyed out of the body before they begin to be active.
“Settlements of this kind may, however, become of importance, if the
bacteria proceed to develop to any unusual extent. This happens when
the contents of the natural cavities in question remains unchanged for
any great length of time, or when (as in catarrh) the normal secretion
undergoes some alteration. The products of bacterial fermentation
may then accumulate to an excessive amount, and products may be found
which do not normally occur. Highly poisonous substances are formed in
many of the bacterial decompositions. One of the most speedily fatal
diseases, septicæmia, is due to blood-poisoning of the system with the
products of bacterial putrefaction, or sepsis.
“Putrid or septic poison may be absorbed by wounds as well as by mucous
surfaces. Septicæmia, which has just been cited as an instance of
septic poisoning, is generally due to wound infection. It is due to the
absorption of products of bacterial decomposition formed in a wound
contaminated by bacteria.
“_Infectious bacteria_ have the power of settling, not merely in
the ingesta and secretions or in dead tissue, but also in living
tissue. This happens chiefly in the mucous membrane of the lungs. The
uninjured skin is protected against invasion by the horny epidermis.
Many bacteria can settle in perfectly healthy mucous membrane. In the
case of others we must imagine that they do not find a proper soil for
their development, unless the mucous membrane is injured or altered. Of
course, injury or alteration of this kind may serve to make the outer
skin or any other accessible tissue, the starting-point of a bacterial
invasion (wound infection). All that is necessary is that a bacterium
should reach a spot that affords the conditions for its development.
If this occurs, it multiplies and forms colonies or swarms. These may,
according to the species of the fungus and the nature of the soil,
remain in aggregation, forming heaps or masses, or may spread through
the tissues. In general terms we may say that local settlements of
bacteria will sooner or later bring about degeneration and necrosis of
the affected tissue. When this may occur, and how widely it may spread,
are circumstances depending on the nature of the bacteria and of the
tissue.
“The inflammatory processes set up by bacterial action may be of very
different intensity and extent in different cases. It may be slight or
transient, or may be severe and issue in suppuration and an abscess.”
The above quotation is perhaps as concise and complete an explanation
as the space in this article will permit, and if thoughtfully
considered, it will be the means of understanding what is to be said of
the disease under consideration.
Pelvic cellulitis is oftener found in childbirth, premature labor and
abortion, for the reason that it is a wound infection, and the female
organism, is always more or less wounded under these circumstances. In
confinement the cervix is always more or less torn, and septic matter
deposited there often speedily spreads along the lymphatics and veins
to the pelvic cellular tissue, in fact, the entire uterine surface
forms a suitable soil for bacterial growth. The vagina is also more or
less injured or bruised through parturient efforts; this may be in the
nature of a laceration or an abrasion of its mucous surface.
Outside of the above causes, the infection may be of traumatic
origin, the most common causes being operative measures on the vagina
or womb of a cutting, scraping or stitching nature, that were not
carried out under strictly antiseptic precautions, guaranteeing the
exclusion of septic germs. Dilation of the cervix with sponge tents or
with instruments or probes that were not perfectly cleansed, causes
infection and a decomposition of the retained secretions, which,
becoming absorbed, leads to pelvic cellulitis. In surgical operations
and puerperal conditions in which infection has been positively
excluded, by careful antiseptic measures, pelvic cellulitis is
impossible.
The inflammation in this disease is excited by the irritating
influences of products of septic decomposition; these may have been
introduced into the system at the time of confinement or of an
operation, or they may have been in the vaginal tract before the
operations were commenced. This teaches an important lesson, which
few seem to have learned; it is this, that _the strictest antiseptic
regulations in a confinement or operation are of no avail, if the
patient herself is not first thoroughly disinfected before the
operation begins_.
In the German Empire there is a legal provision giving full
instructions for the necessary disinfection of the lying-in woman and
her attendant; if there were such a wise provision in this country,
we would not hear of so many deaths of women in childbed, from blood
poisoning. At the Copenhagen International Medical Congress (1884),
Professor Esmarch, one of the most celebrated of German surgeons, said
that “humanity demands antiseptic treatment of wounds and wounded.” I
believe that the time will soon come that antiseptic regulations in the
treatment of diseases will not only be compulsory, but that a neglect
of the same, causing death by blood poisoning, will make the attendant
liable for exemplary damages.
Pelvic cellulitis generally develops itself in an acute form, and the
symptoms are very similar to those of pelvic peritonitis, and, like the
latter affection, there is always an exudation of inflammatory material
in these cases, so that the meshes of the tissues become soaked
like a sponge with water. The invasion of the infection is usually
signalized by a distinct chill or rigors followed by an increased
bodily temperature and a correspondingly rapid pulse. The commencement
of a parametritis is not often without distinct symptoms that affect
the nervous system. The patient feels uncomfortably depressed, a tired,
worn-out feeling overcomes her, she loses her appetite, and there is
pain in the pelvic cavity. This pain is partly due to an accompanying
peritoneal irritation, or in some cases to a circumscribed inflammation
of the peritoneum. Often the pain runs down the groin, along the course
of the great vessels and nerves; this is occasioned from the exudation
pressing on the trunks of these structures in the pelvis. Pain in the
small of the back, and painful defecation, with an irritable bladder,
are due to the same cause.
Phlegmasia alba dolens, or what was called before the dawn of
modern pathological science, _milk leg_, is only another form or a
complication of pelvic cellulitis. This occurs where the infectious
inflammatory process runs along the cellular or connective tissue of
the large vessels and nerves, to the connective tissue of the thighs;
this is a very easy matter, because the vessels and nerves are imbedded
in cellular tissue, and as the vessels leave the pelvis at the groin,
this tissue is continuous with that of the extremities. When the
inflammation gets into the thighs, it invades either the subcutaneous
cellular tissue, that is, the connective tissue under the skin, or it
runs along the trunks of the nerves and vessels; the affected limb
becomes then edematous or swollen, hence the vague term of milk leg,
because the milk has never anything to do with it. One time it was
supposed that this affection is only possible after confinement, but
this is an error, because phlegmasia alba may develop at any time from
purulent infection, originating from any cause.
The so-called puerperal or childbed fever is also nothing more nor less
than an infection of purulent secretion.
The extent of the exudation varies greatly, both in the pelvis and in
the limbs. In the pelvis it is sometimes only a little swelling on each
side of the womb, and between the folds of the broad ligaments, small
nodules the size of walnuts can only be felt, while in other cases
the entire pelvic roof is covered and soaked with the inflammatory
effusion. The consistence of these swellings or tissues feels at first
doughy or soft, but after the absorption has been going on for a while,
it becomes as hard as a board. If the exudation begins to suppurate and
an abscess forms, then the surrounding tissue becomes soft again, so
that the fluctuation of an elastic tumor becomes recognizable.
In the majority of cases the inflammatory process becomes circumscribed
in the pelvis, the fever subsides, and the pain and sensitiveness in
the pelvis disappear. The exudation has also a circumscribed limit,
becoming harder and smaller, until it finally has become entirely
absorbed. In another class of cases, the swelling remains stationary
for a long time and a solid tumor remains in the pelvic cavity, that
may be mistaken for an ovarian or fibroid growth, but in the course of
a long time, it may gradually become absorbed. In a certain proportion
of cases the course of the disease becomes protracted or chronic,
because the effusion is very slow to disappear. In these cases there is
danger of general septic infection or septicæmia, and of a spreading
of the cellular inflammation to the general peritoneal membrane, which
would prove, quite likely, fatal. If the inflammation is violent and
the infection intense, suppuration and abscesses will destroy the
cellular tissue, and if the lower extremities become involved, the
circulation in the affected limb may become permanently injured. The
cellular tissue around the veins, or even the veins themselves, become
more or less affected by the inflammatory process, so that the veins
become compressed or constricted from the cicatrization around them,
or their caliber may become obliterated from inflammation of the walls
of the veins, thus offering a permanent impediment to the return of
the blood to the heart; the affected limb now remains swollen, and the
swelling may entirely subside in the recumbent posture at night, but
during the day it returns again, to make the leg thick and clumsy.
TREATMENT.
Prevention in these affections is much better than cure. The treatment
of a recent case of pelvic cellulitis must be energetically antiseptic.
The seat of the infection must be discovered; the vagina or cavity
of the uterus, as the case may be, must be thoroughly washed out
with a 1 to 2,000 corrosive sublimate solution. After a thorough
disinfection, the inflammation and pain can be checked or controlled
by the application of ice bags; this is the remedy _par excellence_
to check acute inflammatory processes. These bags are preferably of
rubber, about 4x6 inches in size, and when filled with ice and before
applied it is more comfortable to the patient to envelop the bag in a
thin layer of flannel, which takes off the clammy coldness. The patient
should be kept perfectly quiet and the bowels daily moved by a mild
purgative. After the sensitiveness and the fever have subsided, the
absorption of the hardened inflammatory remnants is promoted by the
daily employment of hot sitz baths and the application of tincture
of iodine to the inguinal regions, as well as the use of iodoform
suppositories.
The employment of blistering fluids or plasters is of no particular
value either to check the inflammation or promote the absorption.
If there are symptoms of suppuration forming abscesses, these should be
freely opened into the vagina and their cavities thoroughly rinsed out
with a disinfecting solution.
In the case of phlegmasia dolens alba I have used cold water compresses
fortified by ice bags with brilliant results, but only after all the
other treatments that are laid down in different treatises had been
tried, and failed to give the slightest relief. Among these were hot
fomentations, large repeated doses of morphine, and liniments of
everything that is usually prescribed to relieve pain; for the pain in
phlegmasia is sometimes excruciating.
My experience of the beneficial effects of ice bags and cold-water
compresses in the acute stages of pelvic cellulitis and perimetritis,
led me to believe that the same measures would be useful when the
cellulitis was in the cellular tissue of the extremities, which
constitutes phlegmasia dolens, ignorantly termed milk leg. This
appeared to be heroic treatment to the patient, who dreaded the shock
and feared bad consequences, but she finally consented.
The following was my method: an ordinary large towel was dipped into
iced water, wrung out and clapped around the affected limb, a heavy
flannel roller bandage was then applied from the toes upward to the
groin; flannel is preferable, because it does not get hard when moist
and remains softer under similar conditions than cotton material. On
the most painful parts, like the inner aspects of the thighs, the back
of the flexure of the knee, or popletial region, and the calf of the
leg, I laid rubber bags filled with ice in addition to the cold-water
compresses; these were kept in place by a circular binder independent
and outside of the roller bandage.
The patient is naturally a little shocked when the cold towel is
first applied, but the unpleasantness is only momentary, and then the
reaction brings ease and comfort, so that she desires the ice bags to
be renewed quite often at first, for the patient has now found a remedy
that relieves the pain as nothing else has ever done before. When the
towels become dry and hot, the painful symptoms return, so that they
should be dipped four to six times in the twenty-four hours. If the
sensitiveness on pressure and other indications denote that the acute
inflammatory process is checked, then the compresses and ice may be
discontinued. This treatment avoids suppuration and the formation of
abscesses, while hot applications encourage them.
A mild stimulating diet of milk and egg punch with ten to fifteen
grains of quinine each day should be given in all infectious
inflammations.