The structures in the neighbourhood of the uterus are very frequently the seat of inflammation. This occurs by extension of inflammation from the uterus itself, chiefly in cases of Gonorrhoeal or Puerperal endometritis.

The extension of the inflammation occurs by two different paths. The most frequent is by the Fallopian tubes, producing in the first instance an inflammation of them (Salpingitis and then passing on to the pelvic peritoneum and ovaries, producing a Perimetritis. The other mode of extension is to the subperitoneal tissue, and the result is an inflammation in the loose tissue of the pelvis, a Pelvic cellulitis or Parametritis. It may be said that the one mode of extension usually involves a salpingitis and perimetritis, sometimes with oophoritis, and the other a parametritis.

(a) Salpingitis is an inflammation of the Fallopian tube, and it varies in character and intensity. There may be a simple catarrh extending from the uterine mucous membrane, or an acute septic or gonorrhoeal inflammation.

A frequent result of salpingitis is Adhesion and Occlusion of the tube. The fimbriated extremity is frequently attached to the ovary or to a neighbouring peritoneal surface, this attachment being by connective tissue in the usual fashion of inflammations. The tube is also frequently distorted greatly by the adhesions, doubled on itself, or otherwise altered in position. The uterine orifice of the tube is so small that when the fimbriated extremity is occluded the tube is virtually closed, and the inflammation may completely occlude the uterine orifice as well.

In this case the tube frequently becomes Distended with various contents, and names are applied according to the different character of the contents. In simple inflammations a watery or serous fluid may collect (as there are no glands in the tube, the fluid is not mjucous in character), the result being a Hydrosalpinx. In more acute cases pus distends the tube, Pyosalpinx, or blood may be extravasated, Hematosalpinx. The dilatation of the tubes is sometimes very great, so that a considerable cystic cavity may result.

(b) Pelvic peritonitis or Perimetritis is an exceedingly frequent lesion. It may follow on salpingitis, but the irritant may reach the peritoneum by the tube without the latter being inflamed. It is probable also that inflammation may extend from the uterine Avail to the peritoneum.

The inflammation is usually septic, and is sometimes acute, so as to be suppurative, in which case it may extend to the general peritoneum. But even when acute it may be limited by adhesions, and abscesses may form which remain confined to the pelvis. Such abscesses are sometimes so mixed up with adhesions that it may be difficult to distinguish whether they are in the peritoneum or outside it. They may ultimately burst into the rectum or vagina, or at the cutaneous surface.

Chronic Perimetritis is characterized by the formation of Adhesions and membranous new-formations around the uterus. These are most frequent behind the uterus, uniting it to the rectum. The adhesions are frequently drawn out so as to form long attachments between the parts. Displacements of the uterus and abnormal fixations are frequent results of such adhesions.

The complete picture of perimetritis is that in which the uterus is buried in adhesions which abolish the pouch of Douglas behind, and completely mat together the broad ligament, tube, and ovary, so that the two latter structures are often indistinguishable. The tube may be dilated in the manner mentioned above.

(C) Oophoritis, Or Inflammation Of The Ovary

Oophoritis, Or Inflammation Of The Ovary, mostly occurs in connection with perimetritis. Acute oophoritis is usually a sequel of the puerperal state. A septic perimetritis accompanied by pelvic abscess may be associated with abscesses in the ovaries. The pus at first forms in elongated streaks from the hilum to the periphery, but after a time there are more distinct abscesses. . The Graafian vesicles also frequently become filled with pus. The affected ovary is surrounded by adhesions, and it is frequently difficult to dissect out the organ.

Chronic oophoritis also occurs in connection with perimetritis, but it has sometimes a more independent origin. As the ovary is liable at the menstrual periods to great vascular disturbance, we may have, from checking of menstruation and otherwise, a chronic inflammation set up.

The condition has the characters of interstitial inflammation, ami is comparable to cirrhosis of the liver or kidney, being, like these, accompanied by shrinking of the organ. The capsule is thickened, and the contracting tissue in the organ produces irregular depressions of the surface. The thickening is often peculiarly manifest around the Graafian vesicles, and this, with the thickening of the capsule, may prevent the vesicles bursting. Sometimes a ripe vesicle, instead of bursting externally, ruptures into the substance of the ovary, and so produces further inflammatory disturbance. With these changes in the ovary itself there is usually adhesion of the capsule to the parts around, the chronic inflammation causing the formation of vascular connective tissue which unites opposed surfaces. In this way there may be displacements of the ovaries.

If the Graafian vesicles are prevented from bursting, the fluid which naturally exists in them may become augmented, and the vesicles thus be converted into Cysts (Fig. 450). A limited number of small cysts may thus be formed, and it is not impossible that cysts having this origin may grow to some size, having always the character of simple cysts with serous contents.

It is to be remembered that in old age the ovaries are often shrunk and the capsules thickened, but this is not to be set down as the result of chronic inflammation.

(D) Pelvic Cellulitis Or Parametritis

This consists in a subacute inflammation of the pelvic connective tissue generally occurring after delivery, but also sometimes as a result of operations on the uterus, the introduction of pessaries or the uterine sound, etc. The inflammation is no doubt septic, being in this respect comparable with erysipelas and phlegmonous inflammations generally. The inflammation extends from the uterus, finding its way apparently by the lymphatic spaces. There are the usual results of inflammation, but the exudation is here the most important. The spaces of the connective tissue get filled up with a sero-purulent exudation which may be partly fibrinous. There is in this way a great tumefaction of the subperitoneal tissue, especially of the broad ligament, but also that in front of and behind the uterus and in the pelvis as a whole. The uterus is thus, as it were, fixed in the midst of tumefied connective tissue, which may be felt as a firm swelling on examination per vaginam.

Cystic formation in ovary from dilatation of Graafian vesicles.

Fig. 450. - Cystic formation in ovary from dilatation of Graafian vesicles. (Virchow).

Suppuration generally ensues, but it may do so very gradually, so that it may be long after parturition before it occurs. The pus sometimes extends a considerable distance from the neighbourhood of the uterus. The inflammation may extend and the suppuration follow into the iliac or even into the lumbar region. The abscesses which result open in very various localities, into the vagina, the rectum, or the bladder, or at the surface in the iliac or inguinal region. In these latter cases the condition may simulate lumbar abscess, and mistake is the more likely as the suppuration has perhaps occurred long after the originating cause. The pus discharged has usually the characters of having been long retained, the corpuscles are largely fatty, and there is usually a fsecal odour due to the proximity of the abscess to the rectum.

Puerperal Fever

This term does not express any single definite morbid condition, but includes cases of septic inflammation connected with the puerperal state, in which acute febrile symptoms occur. The fact that the disease occurs in a quasi-epidemic form and is communicable seems to show that it is due to a specific microbe, but it is probable that any of the more virulent pyogenic micrococci, such as that of erysipelas, may induce it. The course of the septic inflammation and the mode of extension to the general circulation vary, but much that has been stated above in regard to perimetritis and parametritis applies here.

There is, to begin with, an acute septic inflammation of the uterine mucous membrane, usually accompanied by sloughing and suppuration. From this local seat there is an extension, in the manner indicated above, by the Fallopian tubes or by the subperitoneal tissue. In the former case a General septic peritonitis results. The septic poison is absorbed, and we have the regular fever of septicemia. In the other case a Septic thrombo-phlebitis may occur, and we have the phenomena of Pyaemia with metastatic abscesses, and septicaemia.

Literature

Bernutz, 1. c.; Matthews Duncan, Prac. treatise on perimetritis and parametritis, 1868; Vikchow, Ges. Abhandl., 1856; Winckel, Dis. of women (transl.), 1887; Bandl, Handb. der Frauenkr., ii., 1886; Heiberg, Die-puerperalen und pyaemischen Proc, 1873. Salpingitis, etc. - Lawson Tait, Brit.. Med. Jour., 1887, i., 825; Lewers, Obstet. trans., xxix., 1887; Polk, (also discussion) Amer. Gynec. Trans., xii., 1887; Hennig, Krankh. der Eileiter, 1876.