PARASITES. Echinococcus.
Echinoccocci have been found fairly frequent in the female pelvis. According to F. Winkel, Neisser up to 1876 collected 44 cases, and Da vaine 13; while Wiener has six cases, including one of his own, in which these tumors formed obstructions to delivery. From the collective inves tigation of the Mecklenburg physicians, we learn the great difference that exists between its prevalence in different places, and its common occurrence in their own country. Very recently W. A. Freund has writ ten a very thorough monograph upon echinococcus disease of the female pelvis, including therein four cases observed by C. Schroder. Freund had already read a paper at the Naturforsehersammlung at Baden-Baden, based on eighteen of his own cases, most of which had been verified by examination. Fr. Schatz has also discussed the subject lately; he has seen five cases himself, and insists upon its frequent oc currence in the female.
Since we have never ourselves seen a case of echinococcus disease in the female pelvis, we will simply follow W. A. Freund in our description.
The echinococcus may reach the pelvis primarily as an embryo, or secondarily as a fully developed parasite by emigration from higher seated organs. It occurs primarily in the pelvic connective tissue, and always at its posterior part, near the intestines and the bones.
The parasite wanders along the connective-tissue planes, getting from the paraproctium into the parametrium and the uterus, into the paracys tium and so to the bladder, into the sub-serosium, and to the iliac fossa. It leaves the pelvis through the sciatic fissure and the lacuna musculorum and vasorum, under Poupart's ligament. Upwards it goes below the parietal peritoneum of the anterior abdominal wall; while below it stretches the structures of the pelvic floor, and almost seems to lie upon the peri neum. It is important for the differential diagnosis, that the parasite pushes its way under the peritoneal covering of the organs, especially of the uterus, and is exceedingly often found between the cervix and laquear vaginae posterior and the rectum. The pelvic connective tissue in the neighborhood of the parasite is in a condition of chronic inflammation.
The echinococcus may be borne in the female pelvis for many years without disturbing the general health, and even without causing local trouble. In very many cases death results from the presence of the para
site in some other organ.
The diagnosis may be made with great probability in the early stages of the affection, when the following condition of things is found: there are one or more round, very smooth, tense and elastic tumors in the postero-lateral portions of the pelvis near the rectum, and in the pelvic connective tissue near the wall of the cavity. They are but slightly mova ble, and not tender. They have no connection with the uterus and its appendages, and the ovaries can be felt to be normal. Finally, local symptoms are absent, and the general health is undisturbed.
A positive diagnosis is to be made by the examination of fluid which has come from the tumors, either spontaneously or after puncture; and Freund warns us of their great danger. The geographical distribution of the disease will also help us in doubtful cases.
The treatment consists in a free opening of the sac, and the evacuation of the parasites. If the tumor is in the greater pelvis or the abdomen, laparotomy is our best resource. If we succeed in completely scooping out the mother sac, which is seldom the case, the wound is to be treated in the same way as after the removal of intra-ligamentous tumors. In other cases the site of operation must be sewn to the abdominal wall, and the cavity be plugged or drained. If the parasite has not grown above the lesser pelvis, Freund only advises operative interference when it causes considerable local trouble. The sac should be freely opened from the vaginal vault, and the wound treated antiseptically.
Besides the atrophy of the pelvic connective tissue, caused by promatritis chronica atrophicans, W. A. Freund described a simple atrophy affecting it, which occurs in wasting diseases, hemorrhages, too frequent childbirth and lactation, and finally after severe puerperal processes. Freund be lieves that the atrophy duo to the latter cause always occurs together with atrophy of the uterus, while that from the former causes are seen with nearly normal womb. Freund considers this simple atrophy to be a cause of hysterical symptoms.