too patulous Fallopian tube. This is most likely to take place when the
egress to the flow has been prevented by a flexion of the uterus sharp
enough to practically destroy the calibre of the cervical canal, as
when the organ has become retroflexed from subinvolution or some other
cause of hypertrophy of the body of the organ. It may, however, occur
as a result of the intense engorgement which sometimes attends acute
suppression of the catamenia. It may occur from disease in the tube
itself, as where a collection of pus or serum has been formed and
thrown into the peritoneal cavity either from rupture of the tube or
discharge through the natural opening at the fimbriated extremity. Or
it may result from hemorrhage following the rupture of a Graäfian
follicle, especially where the disease of the tube has resulted in the
destruction of its calibre or the power of the fimbriæ to grasp the
ovary so as to convey the discharge safely to the uterine cavity.
Hemorrhage from any other source, as from the rupture of a blood-vessel
or of an extra-uterine gestation-sac, usually results in the
development of perimetritis.
Coitus is capable of causing perimetritis when the act is awkwardly
performed, or where there is a disproportion in the relative sizes of
the organs involved, or where the physiological mechanism of copulation
is destroyed by displacement of the uterus, free mobility being lost as
a result.
{229} According to Noeggerrath,[4] a very common cause of perimetritis
is what he is pleased to call a latent gonorrhoea in the male. He
believes that the disease, once contracted, is probably never entirely
eradicated, but that it always exists in a latent form, and that it is
capable of producing a specific inflammation of the pelvic peritoneum
years after an apparent cure had been effected. It is of course
impossible to positively verify this, although he gives some very
striking cases in support of his position. That gonorrhoea in the acute
form may extend by propagation from a vaginitis through the uterine
cavity and Fallopian tubes to the peritoneum, and produce an
inflammation of that membrane, is probable. Cases have been met with
where a history of specific infection was undoubted, in which an attack
of perimetritis followed soon after the initial symptoms and physical
signs of gonorrhoea were manifested. But it is quite another thing to
believe that the specific poison may remain latent and harmless in the
genital system of the male to be transferred years afterward to that of
the female.
[Footnote 4: "Latent Gonorrhoea, etc.," _Trans. Amer. Gynæc. Soc._,
vol. i. p. 268.]
Tuberculous or carcinomatous disease of the pelvic organs is nearly
always complicated by a certain degree of perimetritis.
Perimetritis may result from external injuries, as blows, kicks, and
the like; and under the head of traumatic agencies most of the causes
which have been enumerated would stand as examples; but under this head
I wish also to emphasize the statement that I believe that perimetritis
may result from an unwarranted and unnecessary force used on the part
of the physician in his efforts to outline and locate the position of
the pelvic organs, especially that of the ovaries and tubes. When the
latter organs are in their normal position and not enlarged, it is
usually impossible to outline them by the bimanual touch, nor is it
necessary. When they are diseased the greatest care in manipulation
should be used; and it is often best to administer an anæsthetic, so
that less force may be necessary to determine their exact condition.
The disease may also result from injury inflicted in the medication of
the uterine cavity and in the various operations on the uterus. A most
prolific cause is induced abortion.
Recurrent perimetritis should be regarded as the result of the
persistence of one of the above-mentioned causes. It sometimes recurs
with each menstrual period. Such attacks are often associated with
dysmenorrhoea of the congestive type.
PATHOLOGY, COURSE, AND TERMINATION.--When the pelvic peritoneum becomes
inflamed, and the disease runs through an acute course, the pathology
and termination will be much the same as that described under
Parametritis, for the connective tissue will then be involved in the
process, as well as the peritoneum; not to the same extent, however, as
when the disease begins as a cellulitis. The position of the exudation
tumor, should one form, will be more directly posterior to the uterus
in Douglas's cul-de-sac; it is sometimes larger, and may displace the
uterus far forward. This is more especially the case where the disease
has advanced to the third stage and resulted in abscess.
In the subacute and chronic forms of the disease the course is usually
a slow one. The exudation soon becomes plastic, or is so from the
beginning. This leads to the agglutination of the pelvic organs to one
another, and finally to the production of organized pseudo-membranes
{230} of more or less strength. If the Fallopian tubes and ovaries are
displaced, which is frequently the case under these circumstances, they
are bound more or less firmly in the abnormal position. The adhesions
are sometimes extremely delicate, and embrace the displaced organs as a
net. At other times, or later, they may be so large and firm as to be
readily felt through the vagina. Again, the false membranes may be
broad and ribbon-like, and occupy a position so as to imprison the
displaced organs as though elastic bands were stretched from the
anterior to the posterior portion of the pelvic brim. When Douglas's
cul-de-sac is bridged over and shut off from the abdominal cavity
proper, serum or pus, sometimes both, may collect within it and give
rise, from its round, fluctuating character and rather insidious
formation, to the supposition that it is an incarcerated ovarian cyst;
especially so since it may progressively increase in size and attain
such dimensions as to distend the abdominal walls. This course of the
disease is rare, however.
Under favorable circumstances the course and termination of chronic
pelvic inflammation would probably be much the same as where the
disease is acute--_i.e._ it would run its natural course and end in
resolution by absorption of the effused product. But, unfortunately,
the symptoms of the disease are not violent enough to compel the
patient to go to bed and remain at rest, so as to place the organs in
the most favorable condition for recovery. The affection comes on so
insidiously sometimes that when the patient is finally compelled to
seek relief it may be found that extensive adhesions and considerable
displacement, if not serious disease--especially of the ovaries and
Fallopian tubes--exists. The inflammatory process is progressive, and
will continue to be so until its cause shall be rendered inactive by
the continuous and increasing severity of the symptoms, which force the
sufferer to give up the struggle to remain on her feet and pursue her
usual round of duties.
SYMPTOMS.--If the attack is acute the subjective symptoms of
perimetritis will differ from those described as belonging to
parametritis only in the greater violence of their onset and progress.
The pain, which is usually preceded by a chill, is likely to be sudden,
sharp, and persistent--sometimes agonizing. The pulse, especially
during the first stage of the disease, is small, wiry, and quick,
ranging from 120 to 140 beats per minute. But its character is likely
to change as the affection progresses, and to become full, as when the
connective tissue is the seat of the inflammation. The temperature also
reaches a higher point, rising frequently as high as 104°-105°,
sometimes even higher.
When the disease is chronic from its commencement, the pain is more
obscure, and cannot so certainly be relied upon as a diagnostic sign.
True, a sharp pain existing low down in the pelvis in either iliac
region--pain persistent in character and coming on rather
suddenly--should always direct attention to the probable existence of
an inflammatory condition. The pain of chronic pelvic inflammation is
not attended with the rise in temperature and acceleration of pulse
which have been described as accompanying the acute form of the
disease. There is, doubtless, a slight degree of increase in both, but
not enough to attract attention as a rule. There may be many reflex
symptoms, chief of which are irritability of the bladder and stomach,
the latter manifesting itself in nausea and sometimes vomiting.
{231} PHYSICAL SIGNS.--Physical examination may reveal no evidence of
exudation or of the presence of an inflammatory condition, and may lead
the physician to infer that the attacks are not inflammatory in
character, but that they are of a neuralgic nature. As a rule, however,
examination will show a thickening or an absence of the usual mobility
of the surfaces, and deep pressure may elicit considerable tenderness.
On the other hand, the physical signs may be marked, and the surfaces
may be felt to be quite thickened and very rigid, so that it will be
evident that there is exudation on the surface of the peritoneum.
Usually, the vaginal examination reveals a fixation and induration
posterior to the uterus. If that organ is retroflexed, it is bound
firmly in that position. If the uterus is in its normal position, there
will not usually be the same amount of fulness posteriorly. If an ovary
and Fallopian tube have been displaced, it will probably be fixed in
the post-broad-ligament space or in the cul-de-sac of Douglas. The
pelvic roof, so called, may be found as hard and tense as a deal board,
as was first described by Doherty. The exudation may be so great as to
displace the uterus forward or laterally, and to fix it as though it
were surrounded by hardened lymph. This is especially felt in the
post-uterine space, gluing the uterus, ovaries, tubes, and broad
ligaments together. If there is a small ovarian or fibroid tumor, it
may be likewise fixed in this posterior position.
A later examination may show a change in this condition. The exudation
material may have been reduced by absorption, or there may have been an
increase. If the latter, the disease will probably run an acute course
and end by resolution or suppuration--more likely the latter--and
practically it will then run the course described under the head of
Parametritis.
DIAGNOSIS.--The diagnosis of perimetritis is made with comparative
ease. The subjective symptoms are sometimes obscure, but the physical
signs are perfectly plain. When there is exudation posterior to the
uterus, especially if it has bound the organ in a retroverted position
or incarcerated a foreign body, it is almost absolutely certain that
agglutination is due to peritoneal exudation. This exudation is, as a
rule, not so extensive as that which occurs in parametritis, and if a
tumor is present--which is uncommon--its location is different. Where a
tumor is present as the result of pelvic inflammation, I think that it
may be safely ascribed to connective-tissue inflammation rather than to
peritoneal. On the other hand, where there is simply agglutination, and
where the effusion seems thin and spread out, the organs and ligaments
rigid and thickened, instead of a somewhat circumscribed tumor, the
disease may be ascribed to perimetritis rather than to parametritis.
Where the condition just described is found there can be no doubt as to
the existence of perimetritis.
A small ovarian tumor, abscess of the ovary, pyo-salpinx, fibroid
tumor, fecal impaction, and hæmatocele might be mistaken for this
disease, but these tumors are, as a rule, more or less circumscribed,
while the exudation due to perimetritis is not often so. Perimetritis,
however, may coexist with any of the conditions just mentioned. These
tumors may be bound to adjacent tissues, forming one large mass, as the
result of intercurrent attacks of perimetritis. In such cases the
peritoneal inflammation would exist as a complication.
{232} PROGNOSIS.--When the inflammation is acute, or where the
peritoneum becomes largely involved, the disease may run a very violent
and fatal course. Those cases in which pelvic inflammation is of such
severity as to cause death are usually of this character. As a rule,
however, the prognosis, so far as life is concerned, is favorable.
The prognosis regarding the restoration of the ligaments and the
thickened surfaces to their natural condition, and the restoration of
the displaced organs which complicate the disease, will depend upon the
extent and duration of the affection and upon the treatment. As a rule,
the prognosis is good where the patient has sufficient courage and
fortitude to submit to a prolonged course of treatment, with the
abstemious habits of life which may be necessary.
TREATMENT.--In order to present systematically the therapeutics of
perimetritis it should be divided into the acute and chronic forms, and
the treatment of the latter form will necessarily include to a certain
degree the management of the complications. All that has been said
under the head of the treatment of parametritis will apply to the
treatment of acute perimetritis. As the symptoms of acute perimetritis
are ushered in with greater violence than where the connective tissue
is simply involved, so the remedies for the relief of these symptoms
must be more vigorously applied. The patient must be placed at absolute
rest, and be kept there, for the favorable termination of the disease
will be largely dependent on the faithfulness with which this measure
is carried out. The pain, which is usually great and acute in
character, must be relieved at once by the administration of morphia
subcutaneously in full dose, and the remedy is to be repeated until the
pain is under control, when the effect of the drug may be maintained by
the administration of opium in the form of suppositories containing one
grain of the aqueous extract. As in the treatment of parametritis, so
here, I insist upon the administration of the drug by the above method,
rather than by the mouth, because nausea and interference with the
function of digestion are less likely to follow.
In the peritoneal form of pelvic inflammation the pulse is usually more
rapid and the temperature higher than where the connective tissue alone
is involved. Both of these symptoms may be controlled by the free
administration of opium. If this is not successful, a resort to the
tincture of aconite in small and repeated doses will be indicated. If
necessary, quinia should be administered. This remedy, however, should
not be given unless the temperature remains persistently high; and, as
advised under the head of Parametritis, the dose should not be less
than ten grains, repeated in from four to six hours if the temperature
is not decreased. The action of the tincture of aconite should be
carefully watched, and if its administration is not soon followed by a
lowering of the pulse-rate, its use should be abandoned.
If the disease is of a marked sthenic character, the local abstraction
of blood by the application of leeches to the hypogastrium is often of
great benefit, and poulticing should be most faithfully and
persistently carried out, together with hot applications to the lower
extremities in the form of hot water, as previously directed. I
strongly recommend the application of heat to the hypogastrium in
preference to cold. If the patient be seen quite early in the first
stage of the disease, which is unusual, the application of cold might
be more beneficial than heat; but when the {233} process has advanced
toward the second stage, that of exudation, the application of heat
will facilitate this process, while cold would probably retard it.
By the above plan of treatment--viz. the immediate relief of pain by
full and repeated doses of morphia--it is possible to arrest the
disease in the first stage, but this is not the rule. It usually
advances to the second stage, that of exudation, if it has not already
reached this stage before the patient is seen. A vaginal examination
may now show the uterus to be fixed, but there may be an entire absence
of tumor. Should an exudation tumor exist, it will probably be found
posterior to the uterus, crowding that organ forward rather than
laterally, as would be the case were the inflammatory process seated in
the cellular tissue; or, what is oftener the case, we have mere fixity
of the organ, with thickening of the pelvic peritoneum lining Douglas's
pouch and the posterior surface of the broad ligaments. Later an
exudation tumor will more likely be found. If this is so, it should be
inferred that the connective tissue has become largely involved in the
process, and it should rather be expected that the disease will pass
through the regular course of pelvic inflammation and advance to the
third stage, that of suppuration, as though the disease had originally
begun as a parametritis. It should then be treated on the general
principle laid down for the management of that form of pelvic
inflammation. The case should, however, be regarded with greater
solicitude as to prognosis where the peritoneum has been largely
involved, and the symptoms should be more carefully watched and
counteracted by the application of the proper remedies. There is in
such cases more danger of the disease spreading and involving the
peritoneum generally, and of course becoming an affection of great
gravity. When the peritoneum is largely involved, tympanites, as a
rule, becomes a troublesome symptom, more especially if the disease has
occurred during the puerperal period, and it requires special
attention. The remedy which I have learned to rely upon in the
treatment of this troublesome complication is turpentine, administered
preferably by enema.
Should the disease advance to the suppurative stage, the case then
becomes one of pelvic abscess, and should be managed on the principle
enunciated for that stage of the disease. (See Treatment of Pelvic
Abscess.)
Treatment of Chronic Perimetritis.--When the disease exists in its
chronic form, the uterus, ovaries, and Fallopian tubes may be found
fixed either in the normal position or in some form of displacement,
usually the latter. The peritoneum lining Douglas's pouch, as well as
that covering the uterus, broad ligaments, tubes, and ovaries, will be
found more or less thickened, or the ovaries and tubes may be prolapsed
and retained by false membranes; or the uterus itself may be
retroflexed and fixed by adhesion of the peritoneal surfaces lining
Douglas's pouch and that covering the uterus; or false membranes may
have been formed so as to roof over the pelvis, thereby incarcerating
the uterus and its appendages within that cavity. This condition gives
rise to pains which are rather diffused throughout the pelvis, at one
time affecting the ovarian region in which the disease exists, and at
another being experienced low down in the pelvis and radiating along
the course of the sacral nerve down the posterior portion of the thigh,
always sharp and distressing in {234} character. Where the ovary and
tube are involved the pain usually radiates to the groin and anterior
portion of the thigh. Examination should be conducted with great care,
because, although the uterus and its appendages seem to be fixed
firmly, there are often new adhesions forming or weak ones existing
which may be easily severed; and this especially applies to
manipulation of the ovary and tube, the adhesions of which are, as a
rule, not so firm as those fixing the uterus.
The management of these cases must of course be different from that of
the acute form of the disease. The patient often suffers from nervous
exhaustion, indigestion, and loss of flesh as a result of the long
suffering which she has endured during the course of the disease. I
believe that here the most efficacious plan of treatment is that which
embraces REST as its guiding principle, for the disease probably had
its origin in over-exertion and derangement of the proper relations of
the organs one to another, as in those cases in which it is developed
as a result of prolapse or retroflexion of the uterus or the ovaries,
or from the presence of a tumor incarcerated in the pelvis, which
displaces and holds in malposition the above organs. It is
unquestionably true that where the patient is allowed to exercise and
follow her usual avocation the attrition of the inflamed surfaces upon
each other will tend to keep up the inflammatory condition. It is my
plan, where I can get the consent of the patient, to place her at
absolute rest, and begin the treatment by paying strict attention to
the evacuation of the bowels, for constipation is one of the most
troublesome accompaniments of perimetritis. It often stands in a
causative relation, and nearly always as a complication of the disease;
and of course first attention should be paid to the relief of this
condition.
Strict attention should be paid to the diet. The food should be of the
most nutritious character, calculated to improve the digestive organs,
and through them to build up the general system.
The Local Treatment.--The local treatment should embrace those remedies
which are thought to possess the power of producing absorption of
plastic material, either by a counter-irritant or stimulating action.
The persistent use of the tincture of iodine, both to the hypogastrium
and to the fundus of the vagina opposite the seat of exudation, is of
great value. Where the iodine is found to be so irritating to the skin
as to make it necessary to discontinue its use, and also for the relief
of pain, I have found the following formula very useful:
Rx. Tincturæ aconiti,
Tincturæ opii, aa. drachm j;
Tincturæ iodinii, drachm vj. Misce.
Sig. Poison. To be applied externally as directed.
This may also be applied to the fundus of the vagina instead of the
iodine alone, either by a camel's-hair brush or by the cotton-wrapped
uterine applicator. The vaginal application of iodine should be made
not oftener than once in three days, and sometimes a longer interval is
advisable, especially if the remedy is used in a concentrated form. If
it is found that irritation or ulceration has been produced, its use
must be discontinued for a time, and remedies of a milder form
substituted, as, for instance, the application of iodoform and glycerin
(one drachm to the ounce), or of glycerin alone on the cotton
tamponade.