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 gonorrhoeal infection. He claims that gonorrhoea 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 gonorrhoea, 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 gonorrhoeal 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 diarrhoea; 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 gonorrhoeal 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.