PELVIC INFLAMMATION IN THE FEMALE.
Acute Pelvic Inflammation.—When an infection of the genital organs spreads beyond the organs themselves to the peritoneum or to the connec tive tissues in their immediate neighbourhood, the resulting inflammation is termed broadly pelvic bylammation. In most cases such a condition arises from the spread of a gonorrhoeal or puerperal septic infection upwards through the uterine cavity and along the tubes to the fimbriated abdom inal ostium, and septic fluids escaping thence cause a pelvic peritonitis by direct extension. In other cases, especially in puerperal sepsis, the invad ing organisms spread from the infected surfaces by the lymphatic channels; and the connective tissue around the neck of the uterus and in the base of the broad ligaments is infected—pelvic cellulitis. In most cases, which ever be the original mode of onset, both pelvic peritoneum and cellular tissue are ultimately involved together, and the cardinal symptoms of pain, rise of temperature and pulse-rate are present in both.
The course of the infection varies with its virulence and to some extent with the tissues which bear the brunt of the attack. Thus in pelvic peritonitis more or less serous or sero-purulent inflammatory exudate is poured out and accumulates at the bottom of Douglas's pouch, while fibrinous lymph glues together the ovaries, tubes, uterus and coils of intestine above it. Should the infection be a mild one this exudate may become absorbed, and the only sign of the infection left may be some adhesions around the ovary and tube. More commonly, however, the exudate persists as loculated collections of serum or pus (pelvic abscess) shut in by dense adhesions. In most of these cases the tube is occluded and distended with pus or serous fluid or hydro-sa/pinx).
When the cellular tissue is mainly affected, the inflammation first shows itself as a brawny, tender indurated mass, which may surround the cervix like a collar, or may extend out into the base of the broad ligament. The tendency of such an exudate is to spread in the tissues at the side of the pelvis, and it may overflow into the iliac fossa, or pass forwards between the uterus and the bladder or by the side of the vagina. Sometimes the
exudate becomes absorbed, leaving perhaps tender cicatricial bands which may cause some alteration in position of the uterus. In other cases the mass breaks down in the centre and an abscess is formed, which may point in the vagina or above the pelvic brim in the groin.
The extension of the inflammation either to the peritoneum or to the connective tissue is marked by the patient becoming distinctly worse, and by a rise in her temperature and pulse-rate. Heroic measures as a rule are entirely out of place, and the indications for treatment are to relieve symptoms and to support her strength.
For the relief of pain warm applications are of the greatest value. External applications such as hot stupes, an india-rubber hot-water bag, or a shaped hot-water tin, if the pressure can be borne, or hot poultices over the lower abdomen are useful. Sometimes an ice-bag affords more relief. Internally, a copious vaginal douche of hot saline solution (drachm to the pint), lasting for 15 to zo minutes, and as near F. as the patient can bear, may be given three times a day. If vaginitis or endocervicitis is present the douche may be made faintly antiseptic (Tr. Iodi 111. 11xxx. to Oj., or half saturated Boric Acid solution).
Small doses of Morphia may be required at first to control the pain, but it should be given with the greatest discretion and its use discontinued as soon as possible. Absolute rest should be insisted upon, as movement seems to encourage the spread of the inflammation. The bowels should he opened by a saline aperient (Black Draught 31j. or Mag. Sulph. ass. in ginger-ale first thing in the morning). It should not be forgotten that an appendicitis may simulate or be associated with pelvic inflammation. Should this be suspected on account of the pain and tenderness being right-sided and situated rather higher up in the abdomen, aperients should not be given at this stage (see under Appendicitis). Plenty of nourishment should be given—milk, milk-puddings, whey, eggs, beef tea and beef juice, strained chicken or mutton broth. Rise of temperature above F. should be met by cold sponging.