F With the Compliments of the Author. 
RECURRENT PELVIC PERITONITIS.1 
A CLINICAL LECTURE. 
Delivered at the Hospital of the Philadelphia Polyclinic and College for Graduates in 
Medicine.1 
By B. F. BAER, M.D., 
PROFESSOR OF'-CFyNECOLOGY. 
Gentlemen: This patient is thirty-two years of age, and has been a 
widow two years. She has never been pregnant. The duration of the 
present illness is uncertain. Ever since puberty she has suffered more or 
less from the symptoms of which she now complains. She presented her- 
self ten days ago, and stated that she was scarcely able to be out of bed, 
but being unable to employ a physician she felt compelled to go to a dis- 
pensary. 
Her chief symptoms were sharp pains beginning in the left iliac region, 
deep-seated, and shooting across to the opposite side. She said the pain 
began with the onset of the last menstrual period, and that the flow was 
much more profuse than usual. Her menses usually last four days; at 
the last period the flow continued seven days, and was profuse as stated. 
On questioning her it was learned that she had had numerous attacks of a 
similar character since puberty, especially in connection with the men- 
strual periods, and that of late years these attacks had been increasing in 
severity, the last one being the most severe she had had. The pain is at 
times almost unendurable. She becomes pale, and often during the 
attacks she suffers from nausea, and sometimes from vomiting. There is 
also some distention of the abdomen, with tenderness on pressure. The 
pain is less severe if she occupies the dorsal position, and she finds that 
bending the thighs upon the abdomen affords relief. 
The question of differential diagnosis is an interesting one in a case of 
this character. You will note that the pain here is continuous and not 
intermittent in character, and that position and pressure increase rather 
than relieve it. If you will recall a case which we had in the 
clinic a week ago, you will remember that the symptoms somewhat 
resembled these, in the time of their occurrence—at the menstrual period 
—and in the sharp character of the pain. But in the former case there 
would be an attack of severe cramp-like pain in the centre of the hypo- 
gastrium or a little to the side, which would continue for a variable time, 
to be followed by a discharge of fluid or clotted blood, when there would 
1 Reprinted from the Medical and Surgical Reporter, Oct. 13, 1888. 2 
be an interval of relief, to be followed by another attack. The pain was 
relieved by pressure ; the patient stated that pressure gave her more 
relief than anything else, and that when the menses ceased she was appar- 
ently well. In the present case it is different. After the cessation of the 
flow the patient is unable to be about for days, and does pot recover from 
the soreness and tenderness, but is more or less ill during the entire inter- 
val between the periods. In the first case we found stenosis of the cervi- 
cal canal, and determined that the symptoms were due to obstruction in 
that canal so that the menstrual fluid could not readily flow out. We 
diagnosticated in that case congestive dysmenorrhea the result of stenosis. 
In the present case we found a different physical condition. The symp- 
toms here are inflammatory in character and point to a local peritonitis, 
more especially of the left side; possibly, but not necessarily, involving 
the left ovary and tube. The pain of pelvic peritonitis is sharp in char- 
acter, and radiates from the affected side to the opposite, and often down 
the anterior portion of the limb, especially when the ovary and tube are 
involved. The symptoms here also resemble somewhat those of so-called 
ovarian neuralgia, except that in the latter case pressure relieves the pain 
instead of increasing it; and the disorder is not attended by increase in 
temperature, and is not followed by exudation, although it usually pro- 
duces nausea and vomiting. 
This patient states that she began to suffer at the time of the occurrence 
of puberty ; and on questioning more closely, we find that the symptoms 
at first resembled more nearly those of dysmenorrhea, the result of stenosis, 
due to an imperfection in development. They have since, however, grad- 
ually changed to their present character, which I ascribe to pelvic peri- 
tonitis ; and as the trouble recurs with the menstrual period or from other 
cause, the disease has been properly termed “ recurrent pelvic peritonitis.” 
It recurs for the reason that the original cause and its consequences are 
still active. 
It is probable in a case of this character that there is more or less 
inflammatory action with every period of ovulation, which is relieved or 
modified by the occurrence of the menstrual flow, which depletes the con- 
gested vessels and ends the process for the time. At the following period 
there may be an attack just as severe, and each succeeding attack may be 
more severe than the previous one, until the patient becomes so ill that 
she is compelled to call her physician ; when, if an examination is made, 
it may be discovered that the uterus is only moderately fixed from a slight 
film of exudation on the peritoneal surface, or the exudation may be so 
great as to present a hard, board-like sense to the touch ; or indeed the 
peritoneal pouch may be distended by an exudation so large in quantity 
as to present a well-marked tumor, such as we found in this case. The 
tumor formed in these cases is without shape, or rather it is not circum- 
scribed by a smooth wall as in fibroid or ovarian tumor, but rather takes 
the shape of Douglas’s pouch or the post-broad-ligament space. It is 
usually a little thicker below than above, but the general shape is flat. 
Both the ovary and the tube of the affected side may be involved in the 
inflammatory condition and surrounded by the exudation. In that case 
the tumor would be of somewhat different character. It would be larger, 
and probably circumscribed, but still irregular and fixed. 3 
It is said that this disease always begins as a vaginitis or endometritis, 
and extends to the Fallopian tube, finally involving the ovary and peri- 
toneum. When abscess of the tube or ovary is found to exist in con- 
nection with the peritonitis, the origin is usually ascribed to gonorrhoeal 
infection ; when not attended with the formation of pus it is still said to 
be due generally to some septic material, non-specific or otherwise, admitted 
through the same channel. 
There can be no question that this is true in many instances, probably 
in the majority of cases ; but I believe it is also true that the disease often 
arises from traumatism, the result of congestion from interference with the 
menstrual flow, such as occurs from obstruction in the cervical canal, from 
stenosis or flexion of the uterus. The injury may also arise from coition, 
or from an external blow; or from cold, resulting in suppression of the 
menses. Obstruction in the cervical canal may result in regurgitation of 
menstrual blood through the Fallopian tubes into the peritoneal cavity. 
The obstruction may also be in the tube itself as the result of malformation 
of that organ; or the narrowing may be from inflammatory or other cause. 
Again, there may be such malformation of the fimbriated extremity of the 
tube as to prevent its grasping the ovary at the time of the rupture of the 
Graafian follicle. In the latter case the contents of the follicle would be 
discharged into the peritoneal cavity, and might result in the development 
of peritonitis. Early rupture of an extra-uterine gestation sac is another 
traumatic cause. 
We must explain the development of the peritonitis in some cases from 
causes other than specific or infectious. This patient, for instance, first 
complained when she began to have her menses, and I do not think it 
would be scientific to jump to the conclusion in cases such as this that the 
disease was of gonorrhoeal origin. It is not likely that at the early age 
of puberty a specific cause existed, and it would be unjust to the patient 
to ascribe it to that origin. It is more likely that the origin of the dis- 
ease in this case has been in one of those developmental or traumatic 
causes enumerated above. 
But whatever the cause, when called to a case of this character, you 
should at once make a physical examination, for the purpose of deter- 
mining the locality and extent of the disease, so that a proper treatment 
may be adopted. The patient should be at once placed in bed, for rest is 
one of the prime factors in the management of the case. If great pain 
and tenderness exist, a hypodermic injection of morphia should be adminis- 
tered. This will relieve the pain and facilitate the examination. If the 
necessary manipulation cannot be made without it, ether should be 
administered. The question to be settled first is the diagnosis, and I wish 
here to impress upon you the necessity of gentle manipulative measures, 
for I do not think there is a doubt but that many cases have been injured 
and made worse by rough and awkward examination. First administer 
an antiseptic vaginal douche for the protection of both the patient and 
yourself, and see to it that your hands and instruments are rendered 
aseptic by thorough washing and immersion in an antiseptic lotion before 
they are used. 
This patient was examined at her first visit ten days ago, when I found 
the uterus moderately fixed. On the left side and in the post broad-liga- 4 
ment-space there was a semi-solid mass of lymph extending into Douglas’s 
pouch, flattened in shape and quite tender on pressure. It was not nod- 
ular, and seemed to become thin toward the upper portion, and to be of 
the general shape which you might imagine would be given to liquid glue 
or plaster of Paris which had been poured into a mould shaped somewhat 
as the post-uterine space I made a diagnosis of recurrent pelvic peri- 
tonitis, and ordered the patient to bed. I also ordered certain medicines, 
the first and most important of which was a saline laxative. For the 
relief of pain she was given a vaginal suppository as follows : 
R—Morphise sulph gr. iij 
Ext. belladonnse gr. iij—M. 
01. theobromse q. s. 
Et ft. supposit. No. vi. 
Sig.—One, at night for pain, if necessary. 
She was also ordered the following mixture, to be used a local applica- 
tion over the painful region. 
R—Tr. aconiti rad. 1 -- 
Tr. opii j aa 
Tr. iodini f3vj—M. 
Sig.—Poison. For external use only. Apply with brush to painful surface 
as directed, twice a day. 
She was requested to paint the affected area with this mixture very 
thoroughly twice a day. The next most valuable remedy in a case of 
this character is the hot-water vaginal douche, but it was omitted here 
because of the fear that it would not be administered properly, and might 
consequently result in more harm than good. 
The patient was seen several times in the interval. She reports to-day 
that she is better, and that the pain has almost entirely disappeared. 
This will enable us to make a more thorough examination, and if possible, 
determine the cause of these recurrent attacks. The patient is placed in 
the dorsal position, and with the left index-finger well-warmed and lub- 
ricated I will proceed to make the examination, and describe to you the 
condition which I now find. In the first place, I am glad to be able to state 
that the semi-solid exudation tumor which was found in the post-broad 
ligament-space, at the first examination ten days ago, has almost disap- 
peared ; but in its place there is a hardened, irregular mass, which renders 
the tissues in this region fixed and rigid. I now place the fingers of the 
right hand on the hypogastrium, and by the conjoined manipulation which 
is permitted to-day, because of the absence of great tenderness, I am 
enabled to explore the post-uterine space more thoroughly. I discover 
in Douglas’s cul-de-sac an indurated mass, irregular in shape, which is 
simply an extension of that which exists in the post broad-ligament-space. 
I am unable to outline the ovary or Fallopian tube, or any circumscribed 
or cystic condition resembling disease of those organs. 1 infer, therefore, 
that they are probably not involved in the inflammatory process. 
The cervix uteri is somewhat enlarged, but the os is very small—so 
small, indeed, that I can scarcely detect it with my finger. The body of 5 
the womb is also enlarged and firm, but it is mobile, only the cervix being 
fixed by the indurated exudate described a moment ago. 
The absence of the semi-solid tumor which I discovered at her first visit, 
does not prove that I was wrong in my diagnosis, but simply that the 
serous portion of the mass has been absorbed, leaving the indurated irreg- 
ular condition of the exudated material, which we find to-day. That is the 
history in these cases. Nature attempts, as soon as the inflammatory 
process has reached its height, to restore the parts to their normal condi- 
tion by resolution of the exudate ; but nature only partially succeeds, for 
another attack usually supervenes and arrests the process. Another 
attack supervenes for the reason that the original cause still exists, and 
also because the remains of the previous attack serve as an abiding stim- 
ulus to a recurrence. The original cause of the disease in this case I 
believe to have been contraction or stenosis of the cervical canal, as de- 
scribed. 
What will be the proper course of treatment in the present case under the 
existing circumstances? Will it be proper for me to begin at once a 
treatment for the purpose of rendering the cervical canal patulous, so that 
the menstrual fluid may escape naturally ? If that means dilatation, I say 
emphatically No! for the manipulative measures which are necessary for 
the performance of the operation of dilatation would very probably cause a 
renewal of the disease. 
As a rule, patients who suffer from chronic pelvic peritonitis, which 
this practically is, are more or less broken in general health. They are 
more or less the subjects of nervous exhaustion, indigestion, aniemia, and 
loss of flesh, as a result of the long suffering endured during the course of 
the disease. I believe that here the most efficacious plan of treatment is 
that which embraces rest as its guiding principle. It is unquestionably 
true that when the patient is allowed to exercise and follow her usual 
vocation, the attrition of the inflamed surfaces upon each other will tend 
to keep up the inflammatory condition. It is best, whenever it is possible, 
to remove the patient from the cares of her home, so that she may have 
mental as well as physical rest, free from domestic cares and especially 
from the marital relation. A general regimen, similar to that which was 
introduced by Dr. S. Weir Mitchell for the treatment of nervous exhaus- 
tion, and which consists of seclusion, rest, and diet, together with mas- 
sage and general electricity, is the one which is most beneficial in these 
cases, whilst the local treatment which is necessary is being carried out. 
Strict attention should at once be paid to the condition of the bowels, 
for constipation is one of the most troublesome accompaniments of pelvic 
peritonitis. I believe it often stands in a causative relation, and nearly 
always as a complication of the disease. Strict attention should be given 
to the diet, the food being of the most nutritious character. 
The local treatment should embrace those remedies which are thought 
to possess the power of stimulating the absorption of plastic material, either 
by a counter-irritant or stimulating action. The persistent and free use 
of the tincture of iodine, both to the hypogastrium and the fundus of the 
vagina, is of great value. But iodine alone is sometimes found to be so 
irritating to the skin as to make it necessary to discontinue its use; for 
that reason I am in the habit of prescribing the formula as given above, 6 
consisting of the tinctures of aconite and opium in addition to the iodine. 
This may also be applied to the fundus of the vagina instead of the iodine 
alone, either with a camel’s-hair brush or with the cotton-wrapped appli- 
cator. The vaginal application of the iodine should be made not oftener 
than every three days, and sometimes a longer interval is advisable, 
especially if the remedy is used in a concentrated form. If it is found 
that too much irritation has been produced, its use must be discontinued 
for a time, and then remedies of a milder form may be substituted, such 
as the boro-glyceride, or iodoform and glycerine, one drachm to the ounce, 
or glycerine alone may be used. 
The remedy which I consider next in value to iodine, if not indeed 
preferable to it, is the hot-water douche. But this remedy is liable to be 
abused when placed in the hands of the patient herself. It should not 
go out of the hands of the physician or his trained assistant, the nurse. 
When administered by the patient herself the water is either used at too 
low a temperature or in too small quantity, or both. She becomes tired 
of the pumping and of the position which she must assume, and fails to 
keep it up during the length of time required for the injection of the quan- 
tity usually advised—a gallon or two. The constrained squatting position 
is in itself injurious. I believe that the long-continued use of warm water 
is followed by relaxation of the pelvic organs, and this would constitute 
another objection to the indiscriminate recommendation of this measure ; 
for when it is placed in the hands of the patient she is likely to continue 
its use for too long a period and after the indications for its use have dis- 
appeared. The remedy must be used in accordance with fixed rules, and 
under certain restrictions, and these I would class as follows: 
First. The patient must be in the recumbent posture, and in the dorsal 
position. 
Second. She must not administer the douche herself. 
Third. The water must be at a certain high temperature, which is best 
determined by the sensations of the patient. It should be as hot as can 
easily be borne, and tbe temperature gradually increased during its admin- 
istration, for the patient will be able to endure it at a higher temperature 
after the current has been flowing a few minutes than when it is first begun. 
I believe the douche is better than pumping, by Davidson’s syringe for 
instance, because the application is more likely to be thorough and the 
effect to be maintained longer. For, even when the injection is given by 
the physician or nurse, the hand is liable to become tired of the pumping 
and the application stopped, for a time at least. It is the continuous 
application of the remedy which is most beneficial. For use in my pri- 
vate hospital, I have had made a tripod, five feet in length, with a hook 
in the center on which a bucket is easily hung. The bucket holds two 
gallons of water, and near the bottom is placed a stopcock, to which is 
attached a tube provided with a nozzle and a stopcock at its distal end. 
The patient is placed on a bed-pan, which I have modified after that 
devised by Meriman. The nozzle is then introduced into the vagina, and 
the stopcock at the bucket turned by the nurse, the water being at a tem- 
perature of at least 110° F. The patient can then regulate the flow her- 
self. The water is allowed to enter the vagina, dilating it and flowing off 
slowly, so that the tissues are in a continuous hot bath, which can be kept 7 
up as long as desired—from ten minutes to half an hour or longer—care 
being taken to see that the proper temperature of the water is maintained 
by the addition of a fresh supply from time to time. The important point 
is not so much the amount of water, as its temperature and constant con- 
tact. The application of this remedy should be made once or twice a 
day, depending on its effect upon the patient. 
Recently I have been using “ Gordon’s utero - vaginal irrigator.” 
This instrument does away with the necessity of the pan, which is a great 
improvement. The mechanism of the instrument is simply the placing of 
a bulb similar in shape to that portion of Davidson’s syringe which is 
used for the pumping. This bulb is placed near the end of the vaginal 
nozzle; its position, therefore, is in the orifice of the vagina, filling that 
space so that the water cannot escape except through a return tube which 
passes through the bulb. To this return tube a piece of rubber tubing is 
attached of sufficient length to conduct the water into a receptacle on the 
floor. With this instrument the water can be used at a much higher tem- 
perature, because it does not come in contact with the surface at the 
orifice of the vagina, which surface is more sensitive to the heat than that 
within the canal. Then another great advantage is the getting rid of the 
necessity of the pan. With these precautions in its administration, hot 
water is one of the most valuable remedies which we possess in the treat- 
ment of pelvic inflammations, and great credit is due to Dr. Emmet for 
introducing it and his persistence in keeping the remedy before the 
profession. 
After all tenderness has subsided, much may be accomplished by gentle 
massage of the adherent pelvic organs, but great care and gentleness are 
necessary in the manipulation for fear of producing such irritation that the in- 
flammatory process may be renewed. Then it is very necessary that organic 
disease of the Fallopian tubes and ovaries should be excluded before mas- 
sage is begun, for if pyosalpinx or abscess of the ovary should exist and 
be overlooked, rupture of an abscess might result from the manipulation. 
Before massage is begun, the patient should be placed across the bed, 
the hips resting a little over its edge and the feet placed on the knees of 
the operator. This relaxes the abdominal muscles, and gives greater 
control of the patient, so that the necessary manipulation may be thor- 
oughly carried out. One or two fingers of the left hand should now be 
introduced into the vagina, while the fingers of the right hand are placed 
upon the hypogastrium; then the contracted ligaments, thickened mem- 
branes, and fixed uterus, ovaries, and tubes should be gently manipulated 
aiid moved from side to side, or upward and downward, care being taken 
that the force used is not sufficient to lacerate adhesions, or even so to 
stretch them as to cause undue irritation. The proper amount of force is 
probably best regulated by the sensibility of the patient, and if pain is 
produced by the manipulation it should not be persisted in. This massage 
may at first be employed at intervals of two or three days, but later it 
may be used almost daily for a time. By this method it will almost inva- 
riably be found that the adhesions soon become attenuated and in many 
cases finally absorbed. On the other hand, in long-standing chronic 
cases, the adhesions may be of such size and strength that months may be 
required to produce any marked effect; and in rare cases the adhesions 
may be of such character as to be permanently organized, and almost 8 
incurably to fix the organs. Here operative measures of a nature to be 
described in a future lecture may be necessary. 
In these marked chronic cases I have found, in addition to the massage, 
that stretching of the fundus of the vagina, by packing with antiseptic 
wool, after the method of Taliaferro, sometimes repeated daily, or at 
intervals of two, three, or four days, is of great benefit in overcoming the 
condition. The small rubber colpeurynter, distended with hot water, is a 
very efficient means of accomplishing the stretching, and I have used it 
with great satisfaction in some cases. 
It has been advised that continuous pressure and stretching of adhesions 
be made by means of a large pessary ; but I would strongly urge against 
such practice, for I do not think that good ever comes from it, and it is 
certainly often attended with harm, because the pressure is not equally 
distributed. 
There is another means of stimulating absorption in these cases of pelvic 
exudation which is now attracting considerable attention. That is elec- 
tricity, both by the galvanic and faradic currents. I have been using 
f'aradism during the last few years in many cases of this character with 
benefit, and during the last year I have been using galvanism. I think 
the remedy will eventually take a prominent place, when properly under- 
stood and properly applied, in the treatment of these cases, as it already 
has in the treatment of fibroid tumors. There is no doubt as to the power 
of the strong galvanic current, applied according to the advice of Apostoli, 
to modify the nutrition in fibroid tumors, and generally to ameliorate the 
symptoms. I have had some marked cases to support these views. The 
same will apply to cases of pelvic exudation, and, I believe, also to 
some cases of disease of the tubes and ovaries which have not advanced 
to the suppurative stage. Where pyosalpinx and abscess of the ovary 
exist, the only remedy is the removal of the diseased appendages by 
laparotomy. But I wish here to state that I do not believe that pelvic 
peritonitis is always the result of endometritis or salpingitis, nor that re- 
moval of the appendages is always necessary to effect a cure. I learned 
early in my experience the great value of prolonged rest and thorough 
local and general treatment in these cases. Benefit always follows, and 
in many cases a cure. More cannot be said for removal of the append- 
ages. In some of these cases even removal of the tubes and ovaries does 
not cure the patient. I have, at the present time, under my care two 
of my own operated cases and several that have been operated upon by 
others. The patients are not cured ; they complain as they did before 
the operation. If that is the experience of one individual it is probably 
the experience of all, and will swell the number of uncured cases to many. 
Do not understand me to say that I am opposed to the removal of incur- 
ably diseased uterine appendages, which are a source of suffering to the 
patient, after other proper means have been used to effect a cure; for I 
am an advocate of the operation in such cases, as you have seen, and the 
benefit which sometimes results is marvellous. But I plead for conserva- 
tism, and the exhaustion of means which do not subject the patient to 
an operation which is attended with danger to her life, and by which she 
is unsexed, so far as fertility is concerned ; for many cases will get well 
without an operation, if time is given and skilful treatment faithfully 
pursued.