Inflammation Of The Peritoneum (peritonitis puerperalis), viewed in connection with puerperal inflammations of other serous membranes. - Peritonitis is known as a very common puerperal disease; in rare cases it actually constitutes the original (primary) puerperal exudative process, and as such remains isolated. It more frequently simulates this form, inasmuch as the processes with which it was originally complicated have become retrograde or imperceptible, or have actually ceased after the discharge of their products has been effected. We most frequently find it complicated with the puerperal affections already examined - viz. with the exudative processes occurring on the internal surface of the uterus, with metrophlebitis and inflammation of the uterine lymphatics. The pathogenetic relations of puerperal peritonitis, and especially its relations to the last-mentioned puerperal processes, have been much discussed, but the subject has not as yet been adequately elucidated.

We commence with a statement of the anatomical signs presented by puerperal peritonitis, in reference to its extent and terminations, the quantity and quality of the effusion, and the coexistent degree of reddening and vascular development.

Puerperal peritonitis is not unfrequently limited to the peritoneal covering of the uterus and its appendages, when it presents more or less redness, with more or less distinct congestion and a thin partial lymphatic exudation, or a more dense and extensive layer of a viscid and consistent or loose and fluid secretion.

We not only find the peritoneal covering of the internal sexual organs attacked in this way, but also the peritoneum of the entire hypogastric abdominal region. The disease may even spread over the whole parietal and intestinal peritoneal laminae; the symptoms, however, at the same time predominating on the peritoneum of the internal sexual and adjoining organs.

The entire peritoneum is often uniformly involved in the disease, not only -without any predominance of the symptoms in the sexual organs, but sometimes even with an apparent subordination of these symptoms.

The products of these processes vary very much; they may be firm, yellowish-gray concretions, loose, yellowish, membranous, grumous, gelatinous, or fibrinous coagula, which glue the intestines to one another, or to the parietes of the abdomen, or they may be yellow and greenish-yellow, thin, sero-purulent or thick purulent, dirty green and brownish, red, hemorrhagic, thin, opaque, sanious effusions, the result of septic peritonitis. The product is sometimes very limited in amount, and may merely present a thin covering of the internal sexual organs, or a few membranous or fibrinous flocculi of coagulable lymph, scattered through the abdominal cavity; but in the case of universal peritonitis it is generally extremely copious, whatever the particular variety of the product.

The vascular development and redness is, especially in the last-named cases, very slight, and bears a marked disproportion to the quantity of the exudation.

This fact in itself, and more particularly when examined in connection with combined processes occurring in the uterus, and numerous analogies and observations made at the bedside, justify the views we are about to propound, relative to the genesis of puerperal peritonitis and its connection with puerperal processes in the uterus.

Puerperal peritonitis not unfrequently arises by mere contiguity of tissue, from an exudative process affecting the internal surface of the uterus, or from metrophlebitis. It may remain confined to the internal sexual organs, or become generally diffused, and this occurs the more frequently the more the following circumstance prevails.

The disease is often, and even generally, the result of a primary condition of the blood of the female which predisposes to exudative processes, and is totally distinct from the physiological tendencies of the blood during pregnancy. This proclivity is evidenced by exudative processes on the mucous membrane of the uterus, the intestine, and various serous membranes, by exanthematic processes on the superficial integuments, by a revival of tubercular disease, etc.; and both epidemic and endemic influences and individual causes give it a peculiar character which becomes apparent in the product.

Under such conditions peritonitis will be the more liable to arise, the more the peritoneum has suffered by the revolutions in its local relations during parturition, by the excitement of the large organ, the uterus, which it invests, and by the concurrent disturbances in the circulation; the more exudative processes, or metrophlebitis, and various reactions consequent upon uterine lesions occur in the vicinity of the peritoneum, and especially in the uterine mucous membrane; the more the peritoneum has been previously affected by the contiguity of tissue to the internal sexual organs.

In this case peritonitis is a primary disease, and is either the first and not unfrequently the only puerperal affection, or it occurs, as is more frequently the case, concurrently with an exudative process of the uterine mucous membrane, or soon becomes associated with the latter; it invariably takes its origin in the above-mentioned predisposition existing in the blood.

Like other exudative processes that occur simultaneously or consecutively, we also find that peritonitis is often the result of a secondary disorganization of the blood, caused by the absorption of the products of exudation upon the external surface of the uterus, or by the direct admixture of the products of metrophlebitis with the blood. In this case it presents the characters of a secondary inflammation, and is commonly complicated with exudative processes on other serous, synovial, and mucous membranes, and with capillary phlebitis in the most different organs and tissues, the so-called lobular infarctions (Lobular-Infarcte) and abscesses.

The products of the peritoneal inflammation in either case correspond in character with those of the exudative processes affecting the internal surface of the uterus and of metrophlebitis, whether they occur simultaneously, or whether they precede the former.

Puerperal peritonitis is developed with more or less rapidity, and in the majority of cases proves fatal by inducing abdominal paralysis; or it leaves various morbid sequelae. Those exudative processes are remarkable which result from a very rapid disorganization of the blood, and prove fatal within a few hours, or within two to three days, and are accompanied by paralysis and collapse, affecting the uterus immediately after parturition, and by a sanguineous ill-looking effusion.

Puerperal peritonitis, as may be gathered from the above, is almost always remarkable for its very exudative, or croupy, character.