Figures 19 and 20 illustrate well the described process. Fig. 19 illus trates acute puerperal inflammation of the uterus and parametrium. Fig. 20 illustrates well cicatricial changes in the same structures, following an intense inflammation, as seen post modem. In Fig. 20 there is also a tent like pseudo-membrane arching over Douglas's cul-de-sac, for the represen tation of which the drawing is mainly intended.
Inferring from post-mortem cases, we must distinguish, in parametritis as well as in pelvic peritonitis, two forms of the disease; one severe, occur ring after childbirth or injury to the genital canal, and the other milder, comprising all of the inflammatory affections of the uterus, especially of the parametrium.
In the following pages we will speak of the first form as acute inflam mation, and of the second as chronic inflammation, and of the tissue changes produced by these inflammations as the " residue "of the inflam mation.
Acute Pelvic Peritonitis and Parametritis.
Etiology.—Etiologically these diseases can be divided into two groups, for in a large majority of cases the acute form originates in an intense in fection happening during childbirth, abortion or after injuries, while in other cases, which are milder, the infection is of a less virulent nature, as for instance depending upon blenorrhcea. Occasionally the disease may assume a mild form after childbirth or abortion, while in cases of blenor rhcea it may become very severe.
After normal or abnormal delivery, there is always more or less injury to the mucous membranes and other soft parts, which may become the cause of disease. The results of the injuries vary greatly. The most ex tensive injuries in the course of normal delivery, or caused by the use of clean hands and clean instruments, may have no serious consequences, and hardly produce febrile phenomena. There may be a deep lacera tion of the cervix extending to the parametrium, or even opening into the same, and only cause a slight infiltration into the adjacent tissues; or if a slight blood extravasation into the parametrium has taken place, the connective tissue may become extensively infiltrated; but the process runs its entire course in a few days, with only slight febrile disturbance, and may be only noticed on close examination. This is parametritia, phlegmone pelvis traum$ica of Spiegelberg, which usually also accompa nies local pelvic peritonitis.
More serious are the consequences in cases where the genital tract was injured, or where absorption of septic material from the inner surface of the same, as described by Semmelweiss, has taken place; the septic mate rial may, in debilitated patients, be the result of self poisoning from a wound or decomposing ovum, or it may be introduced from without.
(Infection.) The most severe infections cause death without producing local symp toms; but a large majority of the cases which run their course, with more or less prominent local symptoms, accompanied by fever of greater or less severity, recover, but the changes produced in the pelvic perito neum (adhesions between the organs, unyielding exudations into the parametrium) remain for months or years, and often cause prolonged ill ness of the patients.
The same phenomena may result from operations on the genital appa ratus in non-pregnant women, such as incisions into the cervix, dilatations of the cervix with sponge tents, intrauterine pessaries, internal medica tion of the uterus, or using sounds which have not been disinfected.
Symptoms and of the different pelvic organs present the same symptoms at the beginning. There is no characteristic symptom differentiating between acute metritis, pelvic peritonitis or pare metritis. They all begin with fever and pain in the pelvis and lower part of the abdomen. Only later in the disease do physical signs appear, which differ in the different organs. To illustrate well the difference in the phenomena, we will treat of acute pelvic peritonitis and parametritis separately.
Symptoms of Acute Pelvic all the inflammations of the pelvic organs, this one begins with the most violent symptoms. It may be ushered in with or without a chill, or with rigors. Violent after pains if the disease follows delivery or abortion, violent pains in the lower part of the abdomen if arising from any other cause, fever often with a temperature as high as 104° F., and tympanites appearing early, often limited to the lower part of the abdomen, or to one side, at times singul tus and vomiting, indicate that the pelvic peritoneum participates largely in the disease. General peritonitis may follow on a pelvic peritonitis, and in 98 per cent. prove fatal. In many cases the disease is limited to the pelvis or extends very little beyond. Fever, pain, and tympanites often complicated by diarrhoea, last for one, two to eight days with the same severity, and only the decrease in the tympanites, which is soon followed by decrease in fever and pain, indicates a favorable termination of the disease. An increase and decrease of the dangerous symptoms may follow each other for days, and in rare cases for weeks, rendering the prognosis more unfavorable.