SYMPTOMS AND PHYSICAL SIGNS. A. Acute Peritonitis. Symptoms:-Increased, full, and bounding pulse; increased temperaature; rigor; shooting pains very severe. Physical Signs:-On palpation of lower part of abdomen the patient complains of pain; and the abdominal muscles, apart from the patient's volition, resist pressure. She lies usually on her back, and with both legs drawn up. On vaginal examination the vagina feels hot and tender, and pulsating vessels may be felt in the fornices. After exudation is present we may feel one or other of the following conditions. 1. A flat hard non-bulging condition of the fornices round the cervix, which is not displaced to one or other side but is immobile. The usual simile, and a very good one, is that it feels as if plaster of Paris had been poured into the pelvis. 2. An indistinct fulness high up in the pelvis. This is from free serous exudation. 3. A bulging tumour behind the uterus displacing it to the front; or a tense fluid laterally, apparently in the site of the broad ligament (fig. 45). The former is due to encysted serous effusion in the pouch of Douglas, the latter to encysted serous fluid behind the broad ligament displacing it forwards. As a general rule these effusions are high in the pelvis and symmetrical. Sometimes the bulging retro-uterine tumour feels nodulated after a time; this is from extension of the inflammatory condition into the subjacent connective tissue. Note that the bimanual is often impossible owing to the rigid condition of the fornices and abdominal muscles. The bimanual estimation of effusion is often wrong owing to the fact that we feel the rigid peritoneal membrane through the fornices, and from the rigidity of the abdominal wall draw the conclusion that there is effusion between these. Careful examination under chloroform is of the highest value in such instances. B. Chronic Peritonitis. Symptoms:-These are chiefly backache, sideache, leucorrhoea, increased menstruation and sterility. Pain is the most marked symptom, and is felt most on vaginal examination or coitus. Physical Signs:-On vaginal examination obscure thickening is felt in the fornices. The uterus, if displaced, is often markedly anteverted from cicatrization of the peritoneum in the pouch of Douglas. Very frequently it is retroverted and bound down by adhesions, which may, however, allow of a certain range of mobility. The chronic form remains often as a sequel to the acute; but may develope slowly of itself. DIFFERENTIAL DIAGNOSIS. This will be considered under Cellulitis. COURSE AND RESULTS. Very often the inflammatory condition clears up. The adhesive form leaves its mark in the shape of pathological anteversions, and retroversions bound down (fig. 119). The Fallopian tubes may have their ovum-conducting power so interfered with that an incurable sterility results. When they are not injured to this extent, conception may occur; and the adhesions may ultimately yield to the stretching brought to bear on them by the developing uterus. They may, however, resist this and cause abortion. Occasionally, pelvic peritonitis becomes general and is then rapidly fatal. Serous exudations may become absorbed; pus may dry up, but oftener perforates into the bladder, bowel, or roof of vagina. PROGNOSIS. Each case must be judged on its own merits. We give, therefore, only general hints. As to life.-Pelvic peritonitis is not usually fatal. If it becomes general and is septic or gonorrhoeal in its origin, then the prognosis is very grave. A high and rapid pulse of long continuance, with a temperature not in the same ratio, also makes prognosis grave. As to sterility. This is difficult to give, and often time alone settles the point. The mechanical closure by pressure of the Fallopian tubea condition not diagnosable-and ovaritis rendering ovulation impossible, are conditions often produced and are both incurable. Prognosis as to conception should always be cautious, and never absolute when the peritonitis has been extensive. TREATMENT. A. Acute pelvic peritonitis.—a. Prophylactic. b. General.—(1.) Diet. (2.) Septicity. (3.) Pain. (4.) Pulse and Tem perature. c. Local. a. Prophylactic. This is of the very highest importance. The practitioner should always attend most scrupulously to antiseptic cleanliness in all vaginal, cervical, and uterine operations. Cautions on these points are given under the head of the respective operations and need not be here repeated. During their menstrual periods young patients should avoid all undue fatigue, late hours, violent exercise, alternate exposure to heat and cold when insufficiently clad. Gonorrhoea should be thoroughly treated, especially during pregnancy. b. General. Under this we attend to diet, and employ remedies intended to combat the septic condition when present, to alleviate pain, and to bring down pulse and temperature. (1.) Diet. In the early stages of inflammation, this should be chiefly milk iced or mixed with lime water, potash water or lemonade. Among the better classes, apollinaris or seltzer water can be used. Seltzer water helps to combat the constipating tendency of milk diet. When the patient's strength is reduced and the pulse flagging, nutritious stimulating food must be frequently given. Milk should be still continued; but beeftea or strong soups, every two or three hours, must be added. Stimulants are requisite at this stage, viz., brandy, champagne, gin, or whisky. Care must be taken to give these in their stimulating doses, e.g., for brandy, a table-spoonful every two or three hours. The regulation of the bowels is not requisite in the early stages; but in the later periods must be looked after. Gentle aperients such as compound liquorice powder, colocynth and hyoscyamus pills, castor oil, &c., can be used; and occasional enemata are of service. Enemata should not, however, be used exclusively, as this may lead to the formation of troublesome scybala. When suppuration is tedious, it should be seen that no bed sores form; and iron and quinine should be administered. The bitterness is best masked by dilution with water and not with orange or other syrups, which derange the stomach. (2.) To combat any septic condition.—We know no specific medicine A favourite one is the muriate of iron of the Ed. for this purpose. Phar. B. Tincturæ Ferri Muriatis (Ed. Phar.) Zij. Water Sig. Thirty drops thrice daily in a glass of water. Quinine may be used for the same purpose. Sig. Tablespoonful thrice daily in water. (3.) To alleviate pain.-Nothing is so good for this as the hypodermic injection of morphia deep into the deltoid. B. Morphiæ Bimeconatis Spiritus Vini Rectificati Sig. For Hypodermic injection. gr. viij. miij. 3j. Fifteen minims contain The bimeconate is a good preparation and causes less sickness than other forms; as one drachm of this preparation contains one grain of morphia and as the hypodermic syringe holds only 30 min., it is impossible to give an overdose to an adult. When doses larger than a grain are needed, the hypodermic solution of the acetate of morphia (B. P.) may be employed. Twelve minims contain 1 grain, and therefore 3 minims is the first dose for an adult. It is a good plan for the practitioner to keep the ordinary 8 gr. to 3i solution, and to prescribe the stronger solution only for any patient requiring it; in this way he avoids carrying two solutions of different strength by which mistakes might arise. The stronger solution is prescribed as follows: B. Injectionis Morphia Hypodermica (B. P.) Zij. Sig. For Hypodermic injection. Three minims contain grain Acetate of Morphia. More Chlorodyne (25 min); Battley's solution (liquor morphiæ sedativus, 25 min.); or Laudanum (tinctura opii, 25 min.) may be used. useful than these are morphiæ suppositories. It is a good plan to quiet the pain rapidly with the hypodermic injection; and to keep up the good effect by suppository, ingrain doses every 6 hours, beginning 6 to 8 hours afterwards. See that the patient or attendant understands that the suppositories are to be passed into the empty bowel. (4.) To bring down pulse and temperature.-In early stages tincture of aconite is invaluable. B. Tincturæ Aconiti Sig. Six drops are to be put in Zij. a wine glass containing six Give a teaspoonful every They should be given Drop doses of aconite are of great value. every quarter of an hour until the pulse is reduced and sweating brought on. If this fail and the temperature keep high, quinine in 15 grain doses should be tried. The salicylate of quinine is a good preparation and is given just as quinine is. When the stomach is irritable the quinine, in 20 grain doses, suspended in an ounce of mucilage, may be given per rectum. Sometimes the ice-cap is useful. After the fever has subsided and suppuration is threatened, the strength must be kept up by tonics (such as quinine and iron) and by nutritious food with a judicious amount of stimulant, claret for example. c. Local Treatment.-In the early stages of sthenic nonseptic cases, 8-10 leeches may be applied over the iliac regions. Ice is not generally used as a local application in this country, and has its disadvantages. Of greater use are large hot linseed poultices. They should be made very hot, a layer of flannel intervening between them and the skin, and should be covered with a layer or two of cotton. Such a poultice will be effective for 2 or 3 hours. Blisters and turpentine stupes are good, but soon render the skin so sore that after-treatment by poultices is difficult. The hot vaginal douche (as directed at page 136), with carbolic acid added in septic cases, should on no account be omitted. Encysted serous collections should, as a general rule, be left to be absorbed. When troublesome from pressure, they may be tapped by Matthieu's aspirator. A clear serous fluid, often coagulable, is then drawn off, so like urine that the almost involuntary first thought is that the operator has tapped the bladder by mistake. Pus does not form so often in pelvic peritonitis. It may perforate into the rectum or through the posterior fornix. The treatment of suppuration will be best considered under pelvic cellulitis. B. Treatment of chronic pelvic peritonitis.-When adhesions are |