PERIMETRITIS AND PELVIC PERITONITIS.
THE peritoneum is a delicate, thin, serous membrane, that lines the
whole internal surface of the abdomen and envelopes more or less
completely all the abdominal organs, so that the viscera glide smoothly
against each other with the least possible friction. The peritoneum
dips down almost midway into the true pelvis, and its boundaries
constitute also the limit of the abdominal cavity. That portion of
the general peritoneum, which partly invests all the pelvic organs,
is distinguished from the other by the term _pelvic peritoneum_. When
the entire membrane becomes the seat of inflammation, the affection
is a general _peritonitis_, but when the inflammation is limited to
the organ that it infolds, the prefix _peri_, signifying _around_,
is compounded with the name of the organ, and the suffix _itis_ is
added, which indicates that the peritoneal covering of such an organ is
inflamed, hence, the term _peri-metra-itis_ means inflammation of the
peritoneum around the womb.
Pelvic peritonitis means that the peritoneum of the entire pelvic
cavity is involved in the inflammatory process. This may include the
peritoneal covering of all the other pelvic organs besides that of the
womb as well as the peritoneal folds, that enter into the formation of
the broad and other ligaments of the pelvic organs.
Perimetritis is rarely an independent uncomplicated disease, but
oftener a complication of inflammation of the womb, the Fallopian
tubes, ovaries, or of the cellular tissue that surrounds the organs
and in which they are imbedded. The pelvic peritoneum and the cellular
tissue are so intimately connected with each other by means of their
vessels, nerves and lymphatics, that an inflammation easily runs from
one tissue to another.
If we now inquire into the causes which induce this disease, we shall
find that there is not a single inflammatory disease of any of the
pelvic organs that may not lead to its inauguration. Metritis after
an abortion or a confinement is a fruitful source, so are all the
other causes that operate in exciting metritis indirectly concerned
in this affection. Since etiology or the causation of diseases has
been made a special study in connection with this subject, some
startling discoveries have been made in regard to the origin of pelvic
peritonitis.
Dr. Noeggerath, of New York, has found in the majority of cases that
came under his observation, that pelvic peritonitis, either acute or
chronic, is due to gonorrhœal infection. He claims that gonorrhœa in
the male is in the majority of instances incurable; although it may be
apparently cured, it continues as a latent affection which regularly
infects his female companion. This shows itself at first as a slight
vaginal catarrh, which gradually and stealthily spreads to the cavity
of the womb, thence to the Fallopian tubes and ovaries and afterwards
involving the pelvic peritoneum, for it must be remembered that the
Fallopian tubes open directly into the peritoneal cavity.
Dr. Noeggerath has collected statistics that agree with those of
the celebrated French physician, Ricord, which show that on an
average 80 per cent of the male population have had gonorrhœa, and,
believing themselves cured, when not, enter into married relations,
and unwittingly infect their wives. He says that “it has come to pass
that young ladies dread to marry, because all their friends become
invalids soon after the nuptial rites.” The late Professor Schroeder,
of the Berlin Gynecological clinic, says that “the assertions of
Noeggerath are extravagant, but that he must particularly emphasize
that chronic inflammatory conditions of the internal female genitals,
like catarrh of the vagina and uterus, metritis and perimetritis, are
extraordinarily frequent results of gonorrhœal infection.”
I am inclined to think, from my own experience, that the more
conservative view of Professor Schroeder is perfectly safe and true,
but if Dr. Noeggerath made due allowance for the number of invalids
among newly-married people whose uterine diseases, especially pelvic
peritonitis, were traceable to criminal abortions and monthly probing
of their uterine cavities to induce the menstrual flow, his views would
about coincide with those of the distinguished Berlin authority. These
catarrhal affections cause sterility, and if conception supervenes,
then there is a likelihood of a miscarriage or a premature birth, or a
perimetritis during pregnancy or confinement.
Menstrual disorders in which the flow is either obstructed or
suppressed may also give rise to perimetritis.
Blood poisoning from criminal operations contributes its share in the
causation. Traumatic agencies, like blows, falls, lacerations, and
other injuries during labor, may result in pelvic peritonitis.
Either too hot or too cold vaginal irrigations have given rise to this
affection, and injections into the cavity of the womb for medicinal
purposes, in which some of the fluid escaped through the Fallopian tube
into the peritoneal cavity, has caused, in several instances, fatal
peritonitis. The inflammation of the womb after childbirth invariably
involves the peritoneum. The course and duration of this disease is by
no means uniform.
The disease under consideration is an example of an acute inflammation
affecting a serous membrane.
I have taken pains to inform the reader that the phenomena of
inflammation are always the same, but that the results are modified by
the peculiarity of the structure of which the tissues are composed.
A serous membrane differs completely from a mucous membrane, inasmuch
as it contains neither mucous glands nor mucous cells, and for that
reason can never be the seat of catarrh; instead of this, it possesses
the power to secrete or transude the serous portion of the blood,
hence its name. The serous membrane in a healthy condition has only a
sufficient quantity of secretion to moisten the membrane, but not to
furnish any appreciable quantity of fluid. If the secretion takes place
as a result of congestion, especially when this congestion is due to an
obstruction to the return of blood from heart or liver disease, it is
secreted in such large quantities that it constitutes dropsy.
Under the stimulating influence of the inflammatory process, a similar
secretion is the result, only that it contains also _fibrin_, which
renders the secretion or exudation spontaneously coagulable, and,
further, possesses the capability of passing into the condition of an
organized tissue, either fibrous or granular, and thus forming false
membranes on inflamed surfaces, or solidifying into tumors or swellings.
These inflammations have their various degrees of severity, from a
temporary reddening of the membrane with barely enough effusion of
inflammatory material to cause a thin layer of deposit, to extensive
and violent attacks, that pour out enormous quantities of effusion or
exudation, so as to fill the entire pelvic cavity with a solid mass.
The nature of the inflammatory material may be purulent from the
beginning, because its origin was of an infectious or septic nature.
Suppuration may develop slowly and lead to an abscess; this may open or
break into the peritoneal cavity, causing general septic peritonitis,
which will cause death in a few hours or days. The abscess may also
suppurate and break into some of the adjacent organs or tunnel its
way in different circuitous routes, being guided in its course by the
pelvic and muscular fasciæ, so that it may perforate at the groin,
show itself at the inside of the thighs, or in the lumbar region near
the kidneys. It ruptures most frequently into the rectum, next in
frequency into the vagina and into the bladder. I had a case, that came
under my treatment, in which both rectum and vagina were perforated,
and purulent matter discharged from both fistulæ; under appropriate
treatment the patient recovered completely.
If the inflammation is not of infectious origin, the exudation
gradually becomes absorbed, and each day grows less, until finally
nothing but a few fibrous bands can be felt, and these too may
disappear in time.
The symptoms of perimetritis depend in a great measure on the nature
and severity of the attack.
There are three distinct stages of this disease, and each has its
characteristic symptoms. The first stage is that of inflammatory
congestion, which is generally ushered in with a distinct chill or a
chilly feeling, which is speedily followed by a high fever and a rapid
pulse. The lower abdominal region becomes exceedingly sensitive and
very painful on pressure; the abdomen becomes tympanitic or bloated,
and it is a relief for the patient to draw her limbs up, so as to relax
the abdominal walls. A vaginal examination in this stage gives only
negative results; there is nothing but a painful sensitiveness, great
heat, and the vaginal walls are puffed or swollen; there is as yet no
inflammatory exudation that can be felt by the finger.
After the affection has lasted one or more days, the second stage of
the disease is recognized, this is the effusion or exudation. The
characteristic physical signs of effusion are the only absolute proof
of the existence of this disease. These signs are (1st) an immovable
fixed state of the womb, which is quite the contrary to its natural
healthy state, that permits of a mobility in all directions; (2d) a
hard, non-bulging condition of the tissues that surround the womb,
so that the impression which one receives gives the idea of all the
pelvic organs being cast or set in wax, because everything is glued
down and immovable; (3d) an indistinct fullness is felt by the patient,
high up in the pelvis; this is the free exudation of the inflammatory
material, which has now become solidified and has some characteristics
of a tumor. This may push the organ forward or to either side or
surround the womb on all sides.
The third stage is that of absorption or the gradual disappearance of
the exudation; this is usually a slow process, and may take from three
to six months. I have known residues of the exudation, in the form of
fibrous bands or adhesions or solid lumps to remain for years in the
pelvic or peritoneal cavity. These bands may tie or fix the uterus to
the rectum or to the pelvic walls, so that it will resist all ordinary
efforts to replace it. Pelvic hematocele, or an effusion of blood into
the pelvic peritoneum, inclosed either by anatomical structures or
previously-existing inflammations, greatly resembles the sero-fibrinous
exudation of perimetritis. The pallor of the countenance aided by other
signs of hemorrhage must assist in distinguishing the affections.
Chronic perimetritis is developed in numerous affections of the womb
that exert a continuous irritation of its peritoneal covering. These
are fibroid and malignant tumors, painful and difficult menstruation,
as well as enlargement of the tubes and ovaries. Inflammation of the
uterus and a discharge of blood or matter through the tubes and into
the peritoneal cavity, may bring about a chronic pelvic peritonitis
from the beginning.
Chronic perimetritis or chronic pelvic peritonitis, for the terms are
often interchangeable, is most abrupt in its development, because it
is not heralded by fiery, acute febrile symptoms, but a close inquiry
will usually recall to the minds of patients the commencement of the
trouble. The fact that the peritoneum is also reflected on the bladder,
causes an irritability of this organ, to be the first and only symptom,
for quite a while. There is nothing stereotyped in the development of
any disease, so that the symptoms may or may not be painful from the
beginning. The pains in the pelvis are more or less continual, there is
an incapacity for bodily exertion, the bowels are out of order, either
there is constipation or a chronic diarrhœa; these morbid conditions
destroy the appetite and the patient becomes lean and weakly. From
time to time all these abnormal signs become aggravated, so that the
sufferer may be forced to take to her bed.
Some women have great powers of resistance and endure suffering with
great fortitude, so that they are comparatively free from harassing
pain, although their pelvic organs are tied down by inflammatory
adhesions, and unless they lift or make other unusual muscular efforts,
that increase the intra-abdominal pressure, so as to drag on the
adhesions, they suffer little or no pain. Another sign of chronic
perimetritis is painful intercourse, which jars the adhesions, and this
is particularly the case if the womb comes down quite low. The danger
to be apprehended is that no one knows at what moment some indiscretion
will light up an acute attack with all its serious consequences.
In view of the possibility of any local or circumscribed peritonitis
becoming general, and as such may prove fatal, the importance of
recognizing it in its first stage, or early, becomes readily apparent.
Preventive measures of circumscribed or local peritonitis are to be
found in avoiding the causes that have been referred to as inducing
the affection under consideration, among which, criminal abortions
are the most fruitful. It seems to me that if women were cognizant of
the dangers that threaten them, they would not only be more careful
in observing the ordinary rules of health, but they would voluntarily
shrink from committing crimes that not only stain their souls with the
blood of their own kindred, but also entail disease and death, that
unexpectedly waft their spirits into the presence of their Creator,
whose laws they have outraged. How often have I been told by women who
lay prostrated on their death bed, “O doctor, I did not know that the
induction of an abortion was a crime and dangerous, because the person
who performed the operation told me that it was neither dangerous nor
criminal.” Alas! poor woman, there is no greater crime, and nothing
more pernicious to your health and life; would that others would only
learn and profit from the inexorable fate into which your delusions
enticed you.
TREATMENT.
The treatment in this affection, when prompt and intelligently
administered, offers every chance of success. In the acute stage of
pelvic peritonitis, we must resort to remedies that promptly counteract
the inflammatory action. The internal administration of opium or some
morphine preparation is invariably demanded, not only to relieve the
pain, but also to completely check or constipate the bowels, so that
their peristaltic action is entirely suspended, for their motion would
irritate the peritoneum. Dr. McMunn’s elixir of opium in one-half to
one teaspoonful doses should be given every four hours, until the pain
is relieved and the bowels controlled.
Rubber ice bags should be applied to the lower abdominal region. This
course of treatment will generally limit and check the inflammatory
process in a few days; then the bowels should be gently moved every
day, with an enema of warm water impregnated with a little soap; after
which, complete quietude in bed for another week or two, will complete
the cure.
Chronic perimetritis must be treated according to its complications;
should there be a gonorrhœal infection, then what was said of the
treatment of this complaint elsewhere, applies with equal force to
these cases. The patient’s strength must now be an object of jealous
solicitude. The diet must be of the most nourishing nature, and milk or
egg punch should be the principal food, at regular intervals of four
hours, alternating with strong soups or beef teas, to which a raw egg
thoroughly beaten should first be added.
Vaginal and uterine catarrhs, if they exist, require the attention that
is recommended in the preceding pages.
Warm compresses or fomentations and daily hot sitz baths are of great
value in chronic perimetritis, for they stimulate the healing process
and the absorption. The bowels must now be daily moved, and here I
prefer the patient to employ simply warm water enema in tolerably large
quantities slowly injected, until a quart or more of the fluid has been
thrown into the rectum; these enemas will not only move the bowels,
but also stimulate the healing process. If the patient lies on the
left side while these injections are taken or given, the enema flows
higher up, and it should be retained for a reasonable length of time.
These enemas should only be taken every other day, and between days a
suitable dose of purgative elixir. Tincture of iodine can be applied
to the groins every second day, or iodoform suppositories introduced
into the vagina. Mud baths are also very beneficial in removing old
inflammatory adhesions.
If the exudation suppurates and an abscess forms, it should be freely
opened as soon as possible. This can generally be best accomplished
through the vagina, but if there be a tendency of the abscess to point
towards the groin, then this situation would be preferable, although I
prefer, in even these cases, to make a counter opening in the vagina,
for this precludes the possibility of the abscess sacking or burrowing
further into the tissue. The cavity of the abscess should be thoroughly
rinsed out with a 2 per cent carbolic acid or a 1 to 2,000 corrosive
sublimate solution, and if there is a tendency in the abscess to close
before its cavity is healed out, a rubber drainage tube should be
inserted, so as to give the pus all the possible facility to escape. If
the abscess breaks into the bladder or into the rectum, then a counter
opening into the vagina will greatly insure and expedite recovery.
Sometimes the ovaries and tubes become diseased as a result of the
perimetritic inflammation; this, then, becomes a subject of special
inquiry and treatment. It should hardly be necessary to remind the
reader that sexual relations are to be suspended while there is the
least sign of the affection to be discerned. Although old adhesions and
displacements, the result of old chronic pelvic peritonitis, are often
naturally and permanently removed through a supervening pregnancy, the
intelligent use of the galvanic current will also accomplish that end.