Femina, A Work for Every Woman

by John A. Miller

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.