CHRONIC PELVIC PERITONITIS AND PARA3IETRITIS.
We are well aware of the fact that the denomination that we use for these affections is not quite exact, for they also may be acute at the be ginning and of short duration.
These so-called chronic forms, since they are usually of gonorrhoeal or catarrhal origin, might well be called the gonorrhoeal, but they are often met with in cases where this cause can apparently be excluded; they might also be called " relapsing," although often the process does not recur. Since, however, it is necessary to distinguish between these cases and the severer forms of puerperal disease, we call them " chronic " on account of the frequently recurring relapses.
As these forms of pelvic peritonitis and parametritis are identical in etiology and course, it does not seem advisable to treat of them separately, but it is only necessary to occasionally point out their differences.
Etiology.—The most frequent cause of these forms of peri• and para metritis is, as stated by Noeggerath, in connection with pelvic periton itis, gonorrhcea. The more we observe, the more we are convinced of the great influence the specific virus has in the production of these diseases. We must now admit that husbands apparently cured of gonorrhoea, and all the more where the meatus is occasionally agglutinated in the morn ing, or where there are traces of discharge in the urine, may infect their young wives.
Not only the true blennorrhagic virus, but also its less virulent varie ties, such as those giving rise to vaginitis in children, and mild conjunc tivitis in infants, and possibly other infections, may cause the chronic form of papa- and perimetritis. Infection from dirty fingers, cloths or sponges, contact with persons suffering apparently from simple catarrhal affections, have, according to our experience, frequently caused these affec tions.
According to the virulence of the poison, the first local symptoms vary. If not due to a true virus, it is rare that the entire vagina should become diseased, but only the tender mucous membrane of the cervix, the meatus urinarius, and the mouths of the glands at the introitus, there being present a more or less catarrhal process. From the mucous mem
brane of the cervix sooner or later the affection extends to the walls of the uterus and its Surroundings, especially the lateral and posterior, and thus by the lymphatics to the tubes and ovaries, where it is frequently observed as perisalpingitis and periouphoritis.
This extension of the disease can be traced easily in the genitals of individuals who have not given birth to children. We demonstrated this fact from a number of specimens at a meeting held in Freiburg in 1883.
In women who have borne children, this form of inflammation occurs usually after they have suffered several times from inflammatory disease which has caused permanent injury to the uterus and its surroundings. Such uteri usually are more or less fixed, and frequently eversion and erosion of the cervix and endometritis are present, predisposing to in jection.
The disease is more apt to occur during menstruation, at which period also relapses are more frequent.
The chronic form of the disease at times developes from abraded or ulcerating portions of the vagina or cervix. Wounds caused by pessaries or from friction in cases of prolapsus, are frequently the beginning of the process.
These forms, especially pelvic peritonitis with slight exudation (adhe sive pelvic peritonitis), frequently accompany the development of cysts, carcinoma and other neoplasms, and also hematocele, long-standing hematometra, and extra-uterine pregnancy.
Para-. and perimetritis do not always originate in the genital tract. Often the inner surface of the rectum, which may be impacted with fasces and irritated, becomes the starting-point of the disease. Peritonitis is often produced in this manner during pregnancy and the puerperium, as also apart from these conditions. We have seen two cases not associated with parturition in which an infiltration into the cellular tissue surround ing the cazcum extended to the broad ligaments, forming there a large tumor. It is also probable that the affection has at times its origin from an infected bladder.