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.