CHAPTER XII THE DIAGNOSIS OF PELVIC INFLAMMATION (Part 1)

CHAPTER XII THE DIAGNOSIS OF PELVIC INFLAMMATION {Pelvic Peritonitis and Pelvic Cellulitis) Definitions, pelvic peritonitis and pelvic cellulitis, p. 187. Routes of infection in pelvic inflammation, p. 187. Pelvic peritonitis, p. 188: Anatomy, p. 188. Etiology, p. 189. Varieties, p. 190; Acute pelvic peritonitis, p. 190. Chronic pelvic peritonitis, p. 191; Tuberculous peritonitis, p. 191. Pelvic cellulitis, p. 192: Anatomy, p. 192. Etiology and pathology, p. 192; Pelvic abscess, p. 193. Symptoms, p. 193. Diagnosis, p. 194. Table of differential diagnosis of pelvic inflammation, p. 195. Definition. — The term pelvic inflammation signifies broadly inflammatory action situated in any of the structures occupying the pelvis. It will be used in this chapter to mean inflammation in the peritoneum which covers the pelvic organs, and in the under- lying cellular connective tissue of the pelvis. The inflammatory process when confined to the pelvic peritoneum constitutes a pelvic peritonitis, and when in the pelvic cellular tissue a pelvic cellulitis. Pelvic Peritonitis. — This is a very common affection and accom- panies inflammatory affections of the ovaries and tubes, as well as inflammation of the peritoneum of the entire peritoneal cavity. The inflammation extends to the cellular tissue from propinquity and therefore the two processes are often combined. Pelvic Cellulitis. — This, on the other hand, is a rare affection following labor or abortion and exhibits less tendency to extend to the peritoneum and to the overlying structures. It is often im- possible to differentiate between the two varieties of pelvic inflam- mation, especially in the later stages. An attempt will be made to describe both forms, beginning with the more important: first, saying something of the routes of infection and the character of the structures involved. Routes of Infection in Pelvic Inflammation. — Infection may reach the pelvic peritoneum and cellular tissue (1) from (he outside, through the lumen of the vagina, litems, and tubes, or (2) from the blood current and the lymphatics. 187 188 THE DIAGNOSIS OF PELVIC INFLAMMATION 1. It is possible for infection to travel through the vagina, uterus, and tubes without leaving traces behind it. Often, at the time the patient first comes under observation, the inflammatory processes in these structures have burned themselves out. 2. The blood or lymph vessels may bring infection to the pelvis from distant organs, though this is rare. Generally the infective microorganism is near at hand either in the uterus, tubes, bladder, or rectum, rarely in an infected ovarian cyst, a suppurating appen- dix vermiformis, or the large or the small intestine. Occasionally infection comes to the pelvis in a psoas abscess or other abscess of distant origin, such as an abscess about the sacro- iliac or hip joints. The following bacteria have been found in cases of pelvic inflammation, generally in mixed culture, and they may be classed as causative of the inflammation: — Gonococcus. Colon bacillus. Streptococcus pyogenes. Staphylococcus pyogenes albus, aureus, and citreus. Tubercle bacillus. Diphtheria bacillus. Typhoid bacillus. Pneumococcus. Actinomyces. PELVIC PERITONITIS Anatomy The pelvic peritoneum covers the concave surface of the floor of the pelvis. Beginning on the anterior wall of the abdomen behind the pubes and passing downward and backward, it covers first the posterior surface of the bladder. In this situation it is loosely adherent and has more or less cellular tissue under it. From the bladder it reaches the uterus just below the level of the internal os and thence rises over the anterior aspect of the body of the uterus. This lowest portion forms the so-called vesico-uterine pouch. Passing over the fundus of the uterus, where it is closely adherent, the peritoneum is continued on the posterior surface of the body of the uterus to a point a little below the level of the internal os where it leaves the uterus to dip down deep in the pelvis PELVIC PERITONITIS 1S9 to form the cul-de-sac of Douglas. Its lowest point in the cul-de-sac varies, but averages half an inch or so below the attachment of the vagina to the cervix. Rising from the cul-de-sac of Douglas, the peritoneum reaches first the anterior part of the middle portion of the rectum. Higher up it reaches the sides of this viscus and still higher the posterior portion of the first part of the rectum. At Fig. 70. — Reflections of the Folds of the Peritoneum (Dotted Lines). the sides of the uterus the folds of the peritoneum form the broad ligaments. Above they cover the Fallopian tubes and the posterior surfaces of the ovaries. Etiology Pelvic peritonitis, the more common of the two sorts of pelvic inflammation, is almost always secondary to salpingitis. It may follow the escape of pus or even menstrual blood or injected fluid from the ostium abdominale of the Fallopian tube, or it may follow septic metritis, cystitis, proctitis, perforation of the uterus, appendi- citis, or psoas abscess. The gonococcus and streptococcus are, as far as we know, the bacteria most frequently the cause of pelvic peritonitis. 190 THE DIAGNOSIS OF PELVIC INFLAMMATION Varieties The disease is acute or chronic. Acute Pelvic Peritonitis. — This is manifested by sharp pains in the lower abdomen and pelvis, rigidity of the abdominal muscles, tenderness to examination both of the abdomen and the vagina, fever, rapid pulse, nausea, vomiting, constipation, and nervous depression. The greater the tendency of the peritonitis to become a general peritonitis, the more pronounced are the symptoms. If the resist- ing power of the individual is great, i.e., a high opsonin index is present, and the virulence of the infecting bacteria little, or the dose small, the inflammation may subside, leaving behind it ad- hesions between the opposing folds of peritoneum. Thus the tubes become glued in the cul-de-sac frequently, and coils of intestine are fastened to the tubes. In the severer grades of inflammation the omentum helps to wall off the process from the general cavity of the peritoneum. It applies itself to an inflamed tube in an almost intelligent manner. If resolution does not occur because of the great virulence of the infective material or lessened resistance of the patient, a chronic pelvic peritonitis, or a pelvic abscess, results. Without treatment such a pelvic abscess most commonly opens into the rectum, although it may find exit into the bladder or through the abdominal wall. It very rarely opens into the uterus or vagina. The diagnosis is established by the presence of the symptoms above noted and by the physical signs, which are: — on bimanual examination the vagina is hot, denoting increased body tempera- ture; the uterus is fixed and there is a sense of resistance in the tissues occupying the pelvis, a board-like feeling. This induration of the pelvic tissues, coupled with the rigidity of the abdominal walls and great tenderness to light pressure, make it impossible to map out the contents of the pelvis with exactness. A tumor mass, if present, is high up in the pelvis. The uterus may or may not be misplaced according to the situation of the greatest amount of exudate. If there is an abscess present a point of softening is to be searched for. Abscess, however, is generally rare and, if present, occurs in the later stages of pelvic peritonitis. Speculum examina- tion aids little in the diagnosis of this affection. The uterine CHRONIC PELVIC PERITONITIS 191 discharges are diminished at the onset and increased in the later stages. The detection of a vaginitis may show the origin of a pelvic peritonitis and the isolation of an infective bacterium may show its nature. So also, examination of the rectum or bladder, should symptoms point the way, may help us to find the route taken by the infecting agent in reaching the pelvic peritoneum. Examina- tion of the blood generally shows an increase in the number of white cells, although this is not an invariable concomitant. Chronic Pelvic Peritonitis. — This begins with an acute attack, although the symptoms may be of inconsiderable moment, so as to escape the patient's notice. Often there will be a history of a series of acute attacks separated by intervals of months or years. The symptoms are pain of a dull character in the pelvic region, backache, constipation and painful defecation, disturbance of bladder function, and poor health. Physical examination reveals a larger or smaller amount of exudate and limitations of the mobility of the uterus, tubes, and ovaries due to adhesions. These organs are apt to be displaced as well as enlarged. Tenderness in the chronic stage is not a prominent factor as in the acute form. Pelvic abscess may result in the course of a chronic pelvic peri- tonitis. This will be described more in detail under pelvic cellulitis, as it is more often found in the latter affection. Tuberculous Peritonitis. — Tuberculous peritonitis is one variety of chronic pelvic peritonitis. Here the disease, as seen clinically, is seldom limited to the pelvis, being an affair of the general peri- toneum. The disease begins in the Fallopian tubes in a vast majority of instances, and is sometimes seen and diagnosed before it has reached the general peritoneal cavity. It is characterized by a gradual onset, by fever recurring every evening and disappearing in the morning, rapid pulse, sweating, particularly at night, loss of weight, loss of strength, and anorexia. As the disease progresses there is enlargement of the abdomen due to the presence of plastic exudate or to the accumulation of fluid. Early in the disease nothing characteristic can be made out. An enlargement of a tube, with surrounding exudate, increasing in size when examined at repeated intervals, coupled with a family history of tuberculosis, previous tuberculosis in some other organ, and the symptoms just enumerated, make a probable diagnosis of tuberculous pelvic per- 192 THE DIAGNOSIS OF PELVIC INFLAMMATION itonitis. Elimination of the other causes of salpingitis, such as gonorrhea, may be of assistance. The disease is found most often in virgins. In chronic pelvic peritonitis we do not expect to find leucocytosis, even if an abscess is present, although it may occur. Pelvic peritonitis leaves behind it many disabling lesions in the shape of adhesions and displacements. It is the cause of a large portion of the diseases peculiar to women, and therefore should receive most careful attention at the hands of the physician. PELVIC CELLULITIS Anatomy The cellular tissue of the pelvis lies under the peritoneum. In it pass the blood-vessels, arteries and many large veins, and the lymphatics. It is most abundant in the bases of the broad ligaments and between the peritoneum of Douglas' pouch and the vagina and lower rectum. Therefore, these are the situations where the cellulitis occurs most often. The peritoneum is pretty closely attached to the uterus, Fallopian tubes, and ovaries. That is to say, very little cellular connective tissue is present under the peritoneum in these regions. It is less closely attached to the bladder. Etiology and Pathology Pelvic cellulitis is a relatively rare affection. In more than two-thirds of the cases it is of puerperal origin, and is generally due to infection by the common pus-producing cocci which enter the pelvic cellular tissue from the uterus. Infection may come from the vagina, rectum, or bladder, or from unclean instrumenta- tion or septic manipulation. The trauma incident to parturition opens the way for the entrance of bacteria. The common situa- tions of the inflammation have been foreshadowed in the descrip- tion of the situations in the pelvis where cellular tissue is most abundant. The lymph vessels and veins are affected first. A lymphangitis or a phlebitis may be limited by the plugging of a vessel by a thrombus, and in such a case infection goes no farther. In pelvic cellulitis the infective process extends to the tissue about the vessels, the cellular tissue, and we have a cellulitis. PELVIC CELLULITIS 193 The infective inflammation may go through all three of the initial stages of inflammation, i.e., congestion, effusion, and suppuration, or only the first, or the first two. The process, from a pathological point of view, is not so different from that of a furuncle, namely, infection conveyed into a connective-tissue area. Pelvic Abscess. — If the process goes on to suppuration the pus is evacuated in time spontaneously into the vagina or other pelvic viscera, often doing a good deal of damage before this issue is attained. Should the abscess open into the bladder or rectum, it is unlikely to heal and the patient becomes septic and dies from septicemia after a long illness. This is frequently the result even if most thorough drainage is made, provided intervention has been postponed until the abscess has burrowed extensively into the tissues of the pelvis and the resisting powers of the patient have been reduced to low limits. Early surgical intervention and drainage of the abscess into the vagina result in speedy heal- ing, just as in the case of a boil, with nothing left behind except malposition of the uterus, tubes, and ovaries, and rarely dislocation of the bladder, or stricture of the rectum or urethra. There is no tendency to recurrence and no chronic process as in the case of pelvic peritonitis, where the inflammation originates in the Fallopian tube, which is lined with mucous membrane. It is a well-known fact that infection tends to lurk in mucous membranes, and it does not remain in the cellular tissue. Forms of chronic cellulitis have been described, such as the chronic atrophic cellulitis of Freund, also an edematous form. It is a question, how- ever, whether such processes really originate in the cellular tissue. A pelvic abscess may result from a rupture of a pyosalpinx into the cellular tissue of the broad ligament or of the retro-uterine space. In this case one would expect that the healing process would be more protracted, and such is generally the case. So also in severe grades of cellulitis originating in the uterus, the over- lying tubes and ovaries become infected by extension and have to be reckoned with in the treatment and prognosis. Symptoms The symptoms of pelvic cellulitis -ah' (a) general, those common to infections, i.e., fever, rapid pulse, chills, prostration; and (b) local, 13 194 THE DIAGNOSIS OF PELVIC INFLAMMATION severe pain in the pelvis, sensitiveness to light touch, both of the abdomen and the vagina, also dysuria and painful defecation. The local symptoms abate quickly, even if the process goes on to sup- puration, and most rapidly if resolution occurs. Diagnosis By conjoined manipulation there is found a tumor in the pelvis occupying the region of the broad ligament on one side, or the retro-uterine space behind. The recto-abdominal touch is espe- cially useful in diagnosing this affection. If the mass is in the usual situation in the base of the broad ligament, the uterus is crowded to the opposite side, the tumor, which is hard or boggy to the feel, bulges into the vagina. If the tumor is in the retro- uterine space the lumen of the vagina is encroached upon and the bladder and cervix are crowded forward against the pubes and anterior abdominal wall. In the acute stage there is rigidity of the abdominal muscles, as well as sensitiveness, so-called peritonismus. This soon subsides. In the later stages when there is abscess for- mation it is difficult to find the situation of the uterus without the aid of a sound. There is a mass in the pelvis that may occupy nearly the entire cavity. The pus generally burrows into the retro-uterine space. Rectal examination will often show the upper limits of the tumor; combined rectal and vaginal examina- tion is always of value in mapping out the size and form of the sort of cellulitis that begins in the retro-uterine cellular space. In some cases there is marked edematous thickening in the space between the upper and middle portions of the vagina and the rectum. This is palpated with great exactness by one finger in the rectum and another in the vagina. The detection of fluctua- tion in a pelvic abscess in not easy because thick walls of lymph are effused and encompass a collection of pus of any considerable size. Often an effusion of blood in the peritoneal cavity, a pelvic hematocele of several weeks' standing, simulates a pelvic abscess. The hematocele should have a boggy feeling, not unlike feces of pasty consistency, but on account of the wall of organized lymph with which it is surrounded and the tension of the contents of the sac there may be no boggy feeling. The history of the beginning DIFFERENTIAL DIAGNOSIS OF PELVIC INFLAMMATION 195 of the attack, if obtainable, will throw light on the diagnosis, hematocele being ushered in by severe pain and rectal tenesmus, and with prostration but no fever. Pelvic cellulitis always begins with fever. The sequelae of pelvic cellulitis are not so serious as those of pelvic peritonitis. Neglected cases may leave crippling traces because of the involvement of ovaries, tubes, rectum, ureter, or bladder. Cases which end in speedy resolution, either spon- taneously or because of prompt surgical interference, often leave no other traces than a cicatrix, or a small area of induration in the vagina. DIFFERENTIAL DIAGNOSIS OF PELVIC INFLAMMATION The following table of the differential diagnosis of pelvic inflam- mation has been modified from that in E. C. Dudley's " Text- book of Gynecology": Pelvic Peritonitis. A. Exudate surrounds uterus and is apt to be high in pelvis. B. Uterus fixed wherever it happens to be. C. Pain severe and paroxysmal in acute stage. D. Tendency to suppuration not marked. E. Frequently results in general peritonitis. F. Constitutional symptoms more severe. Apt to be nausea and vomit- ing. Pelvic Cellulitis. A. Tumor usually at one side of uterus and low in pelvis. B. Uterus displaced laterally, not necessarily fixed. C. Pain less severe and more con- tinuous. D. Tendency to suppuration marked. E. Seldom results in general per- itonitis. F. Constitutional symptoms less severe. No nausea and vomiting. Pelvic Peritonitis in Douglas' Cul-de-sac. A.