59 Section of Obstetrics and Gyncecology 1175

(6) Ha3molytic streptococci were found in 42% of all the cases admitted. The
greatest number of these cases followed a normal delivery. Anaerobic streptococci
were found in at least 25% of all cases admitted, and were grown from the blood of
ten cases. -Unlike the cases infected by haemolytic streptococci, every one of these
ten cases followed a complicated labour.
(7) Drainage of the infected uterine and vaginal tissues, and of the uterine
cavity, by the intermittent application of glycerine, has formed the basis of our
treatment. With such treatment together with good nursing, in the open air as
much as possible, a large proportion of the cases have made a good recovery.
(8) Organic arsenicals, particularly metarsenobillon, have been employed in
32 of the more severe cases. MIost of the cases of localized infection have done
very well but we cannot be certain whether the treatment has helped to prevent the
development of peritonitis and septicaemia. In the peritonitis cases arsenicals
appeared to have no influence and in the septicoemic group we have been unable,
except in one or two instances, to sterilize the blood-stream, probably because most
of them are being constantly reinfected from septic clots in large veins. There is at
present no specific treatment which can be relied upon to control these infections.
(9) Very early drainage of the peritoneum in the cases of peritonitis, and late
drainage (if required) of the cellulitis cases, seem to promise the best results.

Observations on the Pathology, Diagnosis and Treatment of

Puerperal General Peritonitis.
By C. OLDFIELD, F.R.C.S., and L. N. PYRAH, F.R.C.S.
GENERAL peritonitis is one of the most insidious and serious catastrophies of the
puerperium; owing to difficulty in diagnosis it is a condition which is very frequently
missed until too late for effective treatment to be carried out.
The incidence of peritonitis in fatal cases of puerperal fever is very high. An
examination of the autopsy records of the Leeds Maternity Hospital between 1924
and 1931 shows an incidence of 58% in the 26 cases which died from puerperal
fever; these figures and those which I have been able to find in the literature
indicate that peritonitis is present at autopsy in approximately one half of all fatal
cases of puerperal fever (Table I). Although some of these cases have a blood
infection, we believe that in most of them peritonitis is the proximate cause of
death.
TABLE I.-FATAL CASES OF PCERPERAL SEPSIS SHOWING THE INCIDENCE OF GENERAL PERITONITIS
Total Cases with
autopsies general peritonitis Percentage
Royal Society of Medicine, 1925 [1] ... ... 35 ... 14 ... 40
North of England 0. and G. Society, 1925 [2] ... 49 ... 23 ... 49
Leeds Maternity Hospital, 1924-1931 ... ... 26 ... 15 ... 58
Kneise [3] (quioted by Williams) ... ... ... 89 ... 4 3 48 ...
199 95 48
The material upon which the communication is based consists of all the cases of
general peritonitis in the Leeds General Infirmary between January 1, 1926, and
December 31, 1931; these cases have been under the care of one of us [C.O.1
and all have been operated upon by us. In addition are included those cases
which occurred at Seacroft Fever Hospital between the same dates and which
were also under the care of one of us [C.O.] ; further, two cases (between the
same dates) from St. James Hospital, Leeds, were communicated to us by
Dr. J. Dick. The main points which have emerged from a study of these cases
will be dealt with.
1176 Proceedings of the Royal Society of Medicine
There were in all 36 cases; of these 25 died and 11 recovered after operation.
In seven cases operation was not undertaken as the patients were almost moribund
on arrival in hospital; a further six cases survived less than twenty-four hours after
operation-so bad was their condition on arrival.
PATHOLOGY.
(1) Pathoqenesis.-In nearly one-third of the cases some form of intra-uterine
interference has been carried out; Table II shows figuires for this and for some other
series of cases. Surgical trauma is thus an important aetiological factor in allowing
the entrance of infective micro-organisms.
TABLE II.- CASES OF PUERPERAL GENERAL PERITONITIS IN WHICH SOME INTBA-UTERINE
OPERATION HAS BEEN PERFORMED.

c 0 -
2~ ~~~~~4
CE5
t, Z ; c
l 0
E-
PO,
C0 C- E a

Gordon [4],1907 ... ... 1 1 - 1 1 - - 1 5 5 10

Wyatt [5], 1927-28 ... ... 1 - 1 - 1 1 - - 6 16 22
Pyrah and Oldfield, 1932 ... 6 1 - - - - 2 - 9 22 31
20 43 63
Peritonitis complicates labour more often than abortion. In this series five
c-ases followed abortion and 31 followed full-term delivery. The infective organism
in abortion is more frequently the staphylococcus and B. coli than the streptococcus
and localized rather than generalized peritonitis results.
Infection by contact with an already infected case may be responsible for a series
of cases of increasing virulence; the earlier cases of such a series show mild
infections only, but the later ones are usually fatal from septicaemia and peritonitis.
Such a series was recorded by Andrews, Maclean and Bourne [1J.
The usual cause of peritonitis in the puerperium is an infection of the peritoneum
from a focus in the genital tract; the infection usually spreads from the endometrium
through the lymphatics in the corpus uteri, but it may result from an abscess in
the uterine wall, in the ovary or the broad ligament or, very rarely, from a
pyosalpinx. There are other occasional and relatively rsare causes-gross trauma,
infection from pre-existing tumours, and acute appendicitis; these have been
discussed at length elsewhere [6]. We shall deal here only with peritonitis arising
from a focus of infection in the genital tract; all the cases in this series and
most of those which one meets in hospitals are of this nature.
(2) Morbid anatomy.-The most interesting changes are those which have been
found in the uterus itself. The endometrium in the more virulent cases shows very
slight inflammation. Microscopic examination shows a very imperfect development
of the protectiDg leucocytic barrier which is present in cases of less virulence.
Scattered groups of round cells and micro-organisms are seen. In cases of less
severity a putrid endometritis may be found; this especially occurs in mixed
infections.
The uterine muscle is softer than normal and, microscopically, shows lymphatics
filled with streptococci. There are three lymphatic plexuses in the uterus-
submucous, intramuscular and subperitoneal-and they intercommunicate freely.
The greatest aggregation of uterine lymphatics is at the uterine cornua; here the
larger collecting lymphatic vessels are found which carry the lymph to the aortic
glands. This large lymph-plexus affords a ready means of direct extension of
infection from the uterine mucosa, through the muscularis to the peritoneum.
Evidences of lymphatic infection are the areas in the muscularis which are infiltrated
by round cells; but very commonly at operation and at autopsy a macroscopic
61 Section of Obstetrics and Gyncecology 1177
uterine abscess is found; sometimes such an abscess has ruptured, resulting in general
peritonitis, while in other cases peritonitis is associated with unruptured abscess.
Uterine abscess has been a prominent feature in this series; it has been present
in 10 out of 36 cases. In six instances the abscess was situated at the right uterine
cornu; it varied in size from that of a pigeon's egg to that of a golf ball, and was
readily felt and seen at operation as a swelling bulging into the broad ligament. The
peritoneal aspect of the abscess was covered with lymph, and sometimes the omentum
was in part adherent to its wall. The abscesses contained thick green pus, and had
evidently been present for several days-or, in some cases, weeks-before the peri-
toneal infection had supervened. In one case the abscess, resembling a large carbuncle
in appearance, was situated at the left uterine cornu and was partly shut off by
omentum and sigmoid colon. In two further cases the abscess was in the posterior
wall of the uterus; in another, two or three miliary abscesses were found at
autopsy.
The Fallopian tubes and ovaries were red and injected, and sometimes slightly
swollen from cedema; if the tube be squeezed, occasionally a drop of sero-pus may
exude, but this is never present along the whole length of the tube nor has a
pyosalpinx ever been found in this series. The tubes were never sealed. Possibly
the small amount of pus found in the tubes had entered from the peritoneal cavity.
In one case in the series an ovarian abscess was found associated with general
peritonitis. In a further case autopsy showed an abscess in the broad ligament
which had followed an infected cervical tear; this abscess had, by spread of infection
through the mesovarium, resulted in an ovarian abscess which had ruptured, causing
general peritonitis.
The peritoneal inflammation is very variable in intensity. In the most acute
cases the serous coat oi the intestines-especially the coils lying in the pelvis-is
much injected and stippled with hemorrhage; here and there are deposits of fibrin
and of lymph. There is either no pus or only a small amount of turbid fluid in the
pelvis. Usually the abdomen contains large amounts of purulent or sero-purulent
exudation, which is very abundant in the pelvis and collects in pools between the
coils of intestines. The intestines are usually moderately or greatly distended, and
are covered with patches of lymph.
In this series bacteriological examination of the pus from the abdomen was only
made in seven cases: in all of them streptococci were found. All the cases, however,
presented the pathological picture of streptococcal general peritonitis.
(3) An analysis of the cases has been made in order to try to correlate the
pathological findings at operation and at autopsy with the clinical aspect and
the prognosis of general puerperal peritonitis. The degree of severity of the infection,
the incidence of local lesions in the pelvis, the association with symptoms and signs
of a blood infection, the time which has elapsed between parturition and the onset
of peritonitis, and the effects of treatment are all very variable factors.
While no rigid subdivision exists, it is possible to divide the cases into two
groups:
(A) Early cases in which the peritonitis develops during the first foutr days after
labour. There are very virulent; they run a very rapid course characterized by
severe toxemia and usually by the absence of any localized inflammatory lesions in
the pelvis. In very many a bacteraemia is present and the prognosis is always grave.
(B) Delayed cases in which the peritonitis develops more than four days after
labour.-Several days or even weeks may elapse. In these a local pelvic inflammatory
lesion is very often found-most often a uterine abscess or an abscess in the ovary
or broad ligament and very rarely in the tube. The peritonitis results either from
rupture of such an abscess or by slow permeation of organisms through its wall to
the peritoneum. There is no bacteraemia and the prognosis is much better than for
cases in Group A.
JtULY-03ST. 2 *
1178 Proceedings of the Royal Society of Medicine 62
Table III shows this series of cases analysed from these points of view. Those
with a short incubation period are rarely associated with a local lesion and have
a very high mortality; those which have a longer incubation period are much
more often associated with local lesions in the pelvis and with a considerably lower
mortality.
Approximately half the cases fall into each group. Some of those in the second
group have occurred two, three, four and seven weeks after labour-they are then
commonly associated with uterine abscess. The cases in Group A are more often to
be found in maternity hospitals; those of the second group have often been discharged
from such a hospital and have usually had little evidence of puerperal infection until
they are re-admitted into the surgical and gynaecological wards of a general hospital
with peritonitis.
TABLE III.-RELATION BETWEEN TIME OF ONSET AFTER LABOUR, PRESENCE OF LOCAL
SUPPURATIVE LE3SIONS IN THE PELVIS, AND MORTALITY.
Time between Labour and Onset of Peritonitis.
4 days or less = 15 More than 4 days = 18 No note available = 3
Died Recovered Died Recovered Died Recovered
13 ... 2 10 ... 8 2 ... 1
Local lesion No local Local lesion No local Local lesion No local
precent lesion present lesion present lesion
3 ... 12 8 ... 10 - ... 3

SYMPTOMATOLOGY.
Do the symptoms and signs of early and delayed cases show any marked
difference ?
A study of our cases shows that they do, but it must be understood that the
division between them is not absolutely rigid.
(1) Early cases.-In these the patient is known to be suffering from puerperal
fever before the onset of peritonitis, by the elevation of the temperature and pulse-
rate. The onset of peritonitis is accompanied by a gradual change for the worse in
the general condition of the patient. There may be a rigor and the temperature and
pulse-rate are raised subsequently. The patient may be able to take food and may
even acknowledge a feeling of well-being. Abdominal symptoms may be very
slight-in one case the patient never complained of abdominal pain-but usually
there is abdominal discomfort and in most cases definite pain is complained of,
The pain or discomfort may pass off, thus misleading the observer. Diarrhoea, when
present as an early symptom, is very suggestive of peritonitis.
The physical signs in the abdomen are very few and difficult to interpret,
Gradually increasing distension of the lower abdomen, spreading upwards, is the
most important early symptom; the abdomen frequently becomes drum-like before
death. Abdominal tenderness is nearly always present, though occasionally the
patient will not admit that there is any. Cutaneous hyperesthesia is frequently
present. Rigidity of the abdominal walls is usually absent. Free fluid in the
abdomen is present in advanced cases, but by the time this is detected the case is
hopeless. The decision to operate must often be taken upon the most indefinite of
physical signs.
(2) Delayed cases.-These cases sometimes show clinical evidence of puerperal
infection before the onset of peritonitis. In very many the infection subsides in
two or three days; very often no evidence of puerperal infection is discernible
before the patient is admitted to hospital with general peritonitis many days,
or even weeks, after labour.
The onset of peritonitis in this group of cases tends to be sudden rather than
gradual, and is usually signalized by the triad of symptoms of a rigor, abdominal pain
An3 Section of Obstetrics and Gyncecology 1179
and greatly increased pulse-rate; when this triad is present peritonitis must always
be seriously considered. After the rigor the temperature rises again and the pulse
remains higher than 120, often being 140 or more. Abdominal pain is nearly always
severe, sometimes agonizing. It is usually continuous in character but sometimes
it occurs in severe paroxysms. At first it is referred to the centre of the abdomen
or to the hypogastrium, becoming generalized later; in cases in which a uterine
abscess is present the pain is at first localized on the same side as the abscess.
The patient appears to be very ill and wears an anxious expression-tbe eyes are
hollow and the cheeks sunken; she lies quite still. There are always definite
physical signs to be found in the abdomen in this group of cases. Rigidity of the
abdomen is always found and is especially prominent in the cases which occur a long
time after labour. Tenderness of the abdomen was present in every case except two
and it is usually generalized. Distension of the abdomen occurs as in early cases.
A mass corresponding to a uterine abscess was found in two cases but normally a,
bimanual examination reveals nothing but tenderness over the position of the uterus.
DIAGNOSIS.
The diagnosis of general puerperal peritonitis is always difficult. A gradual but
persistent change for the worse in the general condition, associated with abdominal
discomfort and distension are the important features of early cases; a sudden
change for the worse associated with the triad of rigor, abdominal pain and greatly
increased pulse-rate are typical of later cases. The anxious facies and the rapid
pulse, of low tension, are important signs. Progressive abdominal distension is
invariable and rigidity of the abdomen is usually present in delayed cases but very
often absent in early cases.
In cases of local peritonitis associated with a palpable mass in the pelvis the
patient does not look so seriously ill, the abdominal pain is usually well localized
and the pulse-rate does not show the combination of rapidity and low tension.
TREATMENT.
We believe operative treatment to be essential in every case in wbich puerperal
general peritonitis is diagnosed if it is due to any organism other than the gonococcus;
we have no reliable evidence that any such cases have recovered spontaneously.
Open ether or gas-and-oxygen are the anesthetics of choice; spinal anaesthesia.
is definitely contra-indicated. Local anesthesia with simple drainage may be used in
emergency, without moving the patient into an operating theatre.
Drainage of the peritoneal cavity should always be done by the abdominal route.
An adequate incision, sufficient to admit the whole hand, is the simplest means of
ensuring evacuation of pus and of making a rapid exploration of the pelvic viscera.
Drainage by the vaginal route may be used as a subsidiary method if time permit
but it fails to allow adequate drainage and exploration of the pelvic organs, so it
should never be used alone.
If an abscess be found in the uterus or in the broad ligament it should be packed
off, opened by sinus forceps and drained by a rubber tube; if an ovarian abscess be
found the ovary should be removed. If no localized focus of suppuration be found
in the pelvis, the uterus itself must be responsible for the infection. Hysterectomy
has been advocated for such cases and also for uterine abscess complicating general
peritonitis. With the single exception of puerperal peritonitis associated with a.
sloughing fibromyoma uteri, we believe that hysterectomy should never be performed
in the presence of general peritonitis. Hysterectomy has been performed on the
supposition that it removed the entire primary focus of the disease. By the time
peritonitis is established the whole of the pelvic lymph-plexus is infiltrated with
streptococci and hysterectomy cannot possibly remove the whole of the primary
focus; such an operation must result in the opening up of new lymphatic vessels for
the further absorption of organisms.
1180 Proceedings of the Royal Society of Medicine 64
COMMENTARY.
It has been frequently stated that puerperal general peritonitis is always a
terminal event in a puerperal blood infection, and must therefore be always fatal.
If this view be held it would be natural to withhold operative treatment. The
object of this communication has been to show that in very many cases puer-
peral peritonitis is associated with-and caused by-a localized focus of suppuration
in the pelvis, and that therefore operative treatment at the earliest possible moment
is indicated.
We believe that the association of septicsmia and peritonitis is not so common
as has been supposed, and this applies especially to those cases in which peritonitis
develops later than the first few days after labour. The reasons for the belief
that puerperal peritonitis is more often a local disease than a terminal event in a
septicaemia are as follows
(1) The peritonleal inflammation is most intense around the uterus and around a
local pelvic suppurating focus, and becomes progressively less further away, exactly as
as in the peritonitis due to acute appendicitis.
(2) Streptococcal infections in any part of the body-finger, cellular tissues, joints
-often mimic a septicemia, as they are associated with a high swinging temperature
and a rapid pulse-rate. That this is due to toxeemia and not septicaemia is evident
by the frequent recovery of such cases and by the absence of a positive blood-culture.
The same applies to puerperal peritonitis.
(3) The prognosis in puerperal general peritonitis-apart possibly from a few
cases arising shortly after labour-depends upon how advanced the condition is
at the time of the operation. If septicaemia were also present no such clinical rule
could be formulated.
(4) A positive blood-culture is by no means always present in patients with
puerperal peritonitis.
REFERENCES.
[1] ANDREWS, H. R., MACLEAN, E. J., and BOURNE, A., Journ. Obst. and Gyn. B. B., 1925,
xxxii, 201.
2] BELL, W. B., DOUaAL, D., et al., Journ. Obst. and Gyn. B. B., 1925, xxxii, 243.
E3] WILLIAMS, W., " Obstetrics," 5th ed., 989 and 1014.
[4] GORDON, A. K., Journ. Obst. and Gyn. B. E., 1907, xi, 468.
[53 WYATT, J. M., Metropolitan Asylums Board Annual Report, London, 1927-8.
L6 PYRAH, L. N., and OLDFIELD, C., 1933, Journ. Ob8t. and Gyn. B. E., xl, No. 1, 8.

Di8cu88ion.-Mr. J. M. WYATT said that with regard to the first paper, the rapidity with
which the tables of figures had been tbrown on the screen made them a little difficult to
absorb completely, but under the heading " septicemia " he thought the mortality rate was low
owing to the somewhat large number of cases of anaerobic blood infections being included.
He agreed that in about 40% of all cases of puerperal infection the bemolytic streptococcus
was the organism concerned, but he himself had found in analysing his own cases, that in
the severe types of infection, viz., septicemia and general peritonitis, in 79 cases, 87% were
due to this organism.
In regard to the B. coli cases, he wondered whether jaundice had been present in
the cases of blood injections and whether the ketonic diet had been used for patients running
a high temperature.
With regard to peritonitis, he was a little uncertain in regard to the very early operation,
i.e., before there were any signs of generalizing, since, out of 183 cases under his care, in 96
there was no evidence of spread above the umbilicus, 93 had made good recoveries, and of
the three deaths, two were from pulmonary emboli; in 87 cases of generalized peritonitis in
which he had performed laparotomy 24 patients had recovered.
He was surprised that Professor Oldfield and Mr. Pyrah had not found a sudden acute
diarrhbea a common symptom of general peritonitis, as he had noticed it in certainly over
70% of his cases.
65 Section of Obstetrics and Gynaecology 1181
Dr. MALCOLM DONALDSON said that, from MIr. Rivett's figures he was not quite convinced
of the value of early exploration of the abdomen. It was difficult to see of what value a drainage
tube could be when there was little or no fluid in the abdomen. The peritoneum's mode of
defence was to pour out fluid, and it was only when sufficient fluid had accumulated to prevent
further secretion that drainage was of any value. He understood that in the cases quoted
by Mr. Rivett there was little or no fluid at the time of exploration.
Mr. CLIFFORD AVHITE said he was surprised that more stress had not been laid on the
importance of the pulse-rate in diagnosis. He had seen cases in which, for a time, the only
sign had been an increasing pulse-rate-all the other signs and symptoms being absent. Then
quite quickly the classical signs of established peritonitis had become obvious. In his opinion
the description given by Professor Carlton Oldfield was that of established and not really early
peritonitis. To obtain good response to treatment it was no use waiting for the appearance
of all the classical signs and symptoms.
Dr. O'DONEL BROWNE (Dublin) said he would like to ask Mr. Rivett what was his exact
technique in obtaining cultures from the uterine cavity.
He felt that insufficient attention could be paid to clinical findings, and agreed with Mr.
Clifford White regarding the importance of pulse-rate. Subinvolution of the uterus was also
of the greatest importance. When this condition was associated with fcetid lochia, between
the eighth and tenth days of the puerperium, especially if there was any uterine irregularity
or tenderness, with suggestion of fixation, the case was eminently suitable for hysterectomy.
Once there was either general peritonitis or septicemia, operation was of no avail.
Professor OLDFIELD (in reply) said that statistical tables relating to the incidence of
puerperal sepsis would be more helpful towards the settlement of the important question
of the origin of infection if the cases were divided into those patients who had been
examined vaginally and those who had not had any such examination before, during,
or after labour. From his long experience of puerperal sepsis, he had concluded that infection
was introduced into the passages before, during, or after labour in practically all cases. As
to treatment he considered that intra-uterine applications were unnecessary and not free
from danger. Moreover, he thought that sera, vaccines, pituitary extract, and other forms
of medication were useless and not free from the risk of hindering the recovery of the
patient, although it was not uncommon to see a patient's temperature drop suddenly after
any form of treatment.
With regard to puerperal general peritonitis, be wished to add a word or two on
early diagnosis. Early diagnosis was sometimes difficult, and the most important point
was a change for the worse in the general condition of the patient. Pain was usually
severe, but occasionally it was not a prominent feature. Similarly, distension, vomiting
and diarrhcea, and rise in pulse-rate and temperature were variable in their incidence and
severity. He agreed with Mr. Clifford White that acceleration of pulse-rate was a very
important sign.
Mr. RIVETT (in reply) said he was much interested in Professor Oldfield's and Mr.
Pyrah's paper in that it recorded so many cases of peritonitis appearing late in the
puerperium. In reply to Professor Oldfield he suggested that the fact that in three cases
of " B.B.A. " the patients had died from peritonitis was strong evidence that infection could
occur without interference. Professor Oldfield had said that the diagnosis of peritonitis was
easy. They had not found it so at Queen Charlotte's Hospital, and in five cases had only
discovered it post mortem.
In reply to Mr. Donaldson, Mr. Rivett agreed that in some of these early cases a diagnosis
of peritonitis could not be established when no organism had been found at the operation,
The fact that recoveries had taken place except when the blood was also infected satisfied
him that the exploratory operation did no harm.