A system of practical medicine. By American authors. Vol. 4

by Unknown

ETIOLOGY.—All of the causes which have been enumerated as capable of producing parametritis may be included in the etiology of perimetritis. If, however, the great predisposing causes of the former—abortion and injury at parturition—be absent, the woman be non-parous, the inflammation will affect the peritoneum rather than the connective tissue. Parametritis is rare before pregnancy has occurred, except in so far as the connective tissue always becomes more or less involved when the peritoneum covering it is inflamed. Perimetritis, on the other hand, is frequent in the single and sterile woman. But, as a rule, it does not run the same typical acute course. It is usually subacute or chronic from the beginning, and results in the formation of false membranes which bind the pelvic organs to one another.

Perimetritis of the adhesive form may be produced by the pressure and irritation resulting from displacement of the pelvic organs, as retroflexion of the uterus, incarcerated fibroid or ovarian tumor, prolapse of the ovary and Fallopian tube, fecal impaction, and from ill-fitting and improperly-adjusted pessaries. Under these circumstances the disease usually comes on insidiously, with no acute symptoms, and runs a slow course. It may be discovered accidentally when making an examination on account of pelvic pain obscure in character, or when the attention has not been called especially to it by the presence of specific symptoms.

Perimetritis may result from regurgitation of menstrual fluid through a 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.

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.

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.