pus (purulent peritonitis) is present, pain is not marked and may be entirely absent. Where a sudden sharp outpouring of lymph takes place, the pain is severe and continuous. It is exceedingly difficult to say how much pain is the result of the involvement of the peritoneum, and how much is caused by coincident inflammation of uterųs, ovaries or tubes. Movement of the organs over which lymph is effused increases the pain. Sudden pelvic pain, accompanied by grave general symptoms, pyrexia, and septicemia, and followed by a rather abrupt cessation of the pain, points to purulent peritonitis.

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Temperature.-Where serum alone is produced, the temperature is seldom elevated one degree. (I consider 993° as normal rectal temperature.) The height of the fever accompanying lymph effusion will vary with the patient's general condition, the kind of infection present, and the degree of the infection. Gonorrheal peritonitis rarely produces a temperature above 1021⁄2°. The same is true with staphylococcus infection. In streptococcus poisoning the temperature rapidly reaches 103°, and is more often above than below that point. The evening temperature is generally a degree above the morning. A temperature holding steadily for more than a day above 103° should create great uneasiness in the medical attendant. This is particularly necessary when the fever comes on after operation, abortion, or labor. There are marked fluctuations in the temperature in most cases. The falls in temperature will be found to correspond pretty accurately with an increased excretion of urine and evacuation of the bowels. Through the kidneys and the bowels toxins are elimiuated.

The pulse in gonorrheal peritonitis seldom reaches 110 Where the infecting agent is the streptococcus, the pulse rarely falls below 110° beats a minute. Of more value in determining the nature of the infecting agent than either pulse or temperature alone, are their relative marks. Thus, a temperature of 103° with a pulse less than 110° need cause little apprehension as to

the ultimate result, while the same temperature with a pulse of 130° calls for immediate interference, and is indicative of a virulent infection, probably streptococcic. The effusion of lymph does not cause the rapid pulse and fever. Great masses of lymph may be thrown out about a gauze drain in the pelvis, and yet the pulse be but slightly accelerated and fever be absent. The fever and quick pulse accompanying those degrees of infection which result in lymph effusion are produced, not by the lymph, but by the toxins of the invading germs. We find slight rise in temperature attending the production of large plaques of lymph, and high temperature where no lymph is produced. The fever is due to the toxemia, not to the outpouring of lymph

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Rigors.-Chills are not features of peritonitis, except when there is a sudden rise in temperature from a point near IOI to one 4° or 5° higher. Then a slight rigor will mark the inception of the rise in many cases. Rigors may be stated to be features rather of a general septicemia than of a localized peritonitis.

Digestive Symptoms.-There being an overproduction of bile, vomiting is apt to follow overloading the stomach in cases of pelvic peritonitis. Beyond this, vomiting is rarely present as a symptom of pelvic peritonitis. The onset of persistent vomiting, where not produced by improper food and drugs, if accompanied by high pulse and temperature, is alarming. It is indicative of a peritonitis which is extending above the pelvic brim. The bowels are prone to costiveness in pelvic peritonitis, on account of interference with their peristalsis by adhesions, and in part to the increase in pain produced by defecation. In purulent peritonitis there is, on the contrary, very commonly a diarrhea.

The kidneys are rarely affected in any forms of infection save one. The urine is increased in amount and the percentage of urea is increased. In streptococcus infection. acute parenchymatous nephritis is a common complication.

The heart and the lungs are not affected in any form of

peritonitis, except that due to streptococcus, the purulent form. Endocarditis, pneumonitis, and pleuritis are very often met with in cases of purulent peritonitis. It is rare for a case of streptococcus infection to recover without some grave complication.

Diagnosis. The diagnosis of pelvic peritonitis is generally embraced in that of some one of its accompanying lesions, salpingitis endometritis, etc. It is not so difficult to detect an effusion of lymph in the pelvis. I have never been able to determine the presence of the serum which I have evacuated so many times. The important and difficult task is to diagnosticate the presence of primary purulent pelvic peritonitis. I may mention the more usual features of this disease: usually a history of criminal abortion or instrumental labor, often an initiative chill, pulse from the first 110° or more, temperature at or above 103°, tympanites, not much pain, stupid face, tendency to somnolence, sordes on teeth, red furred tongue, muttering delirium; uterus fixed in pelvis, vaginal vault hardened, spongy mass in posterior cul-de-sac, not much sensitiveness. The woman looks very ill in a a day. It is especially difficult to differentiate suppurative pelvic peritonitis from general suppurative peritonitis. I have never found a case of suppurative pelvic peritonitis in which there was not a history of either abortion, labor or trauma. In general suppurative peritonitis there is no such history; it is usually due to appendicitis. It is impossible to determine just when a suppurative peritonitis arising in the pelvis ceases to be pelvic and becomes general.

Prognosis. Where the effusion is purely of serum and lymph there is no risk to life. All cases of purulent peritonitis die unless operated upon, and most of these perish. In early surgical interference lies the only hope of saving the lives of these women.

If lymph effusions are allowed to remain they produce permanent lesions.

When a woman has once had pelvic peritonitis with the production of lymph she has before her all her life.

The prog

the possibility of an operation of some sort. nosis of peritonitis is markedly influenced by the nature of the causative lesion, whether gonorrheal endometritis, salpingitis, pelvic lymphangitis, etc. These are discussed elsewhere.

Treatment.If an effusion of serum alone is suspected the treatment consists in preventing further extension of the process by removing the causative focus of infection. The serum will then be absorbed. If lymph is effused, the cul-de-sac should be opened, and all attachments between the viscera should be severed, after the focus of infection (usually the uterus) has been cleansed. (See Exploratory Vaginal Section). This is necessary because the lymph in contracting into bands produces such distortion of the viscera as will destroy their function, partially at least. It is to prevent tubal and ovarian suppuration, as well as future adhesions, that this operation is recommended. (See Salpingitis.)

SUPPURATIVE PELVIC PERITONITIS demands the most energetic measures. The operation to be applied is purely an evacuative one. In most cases it will suffice to open the posterior cul-de-sac, let out the pus and fill the pelvis with iodoform gauze. But in all cases of purulent peritonitis, the Mikulicz dressing of iodoform gauze is absolutely necessary to remove the large quantities of septic fluid which escape after the operation, and to furnish iodine in the form of iodoform in order that the streptococci may be destroyed. The author has shown that this result follows the use of a certain form of gauze in these cases.

I have had no experience with the use of antistreptococcus serum in these cases, and cannot see how it can benefit them before an operation. Given after an operation it may prevent those complications which commonly cause death. Certainly, preliminary reports warrant its trial, but not to the exclusion of measures here recommended.

GENERAL TREATMENT.-When a heart stimulant is

needed in pelvic peritonitis I employ strychnin. As a rule this will be found necessary in the purulent type only. Here large doses must be administered, beginning with gr. q. 4. h. hypodermically and gradually increasing. I dislike to give alcohol except in the form of champagne. If strong liquors are given, brandy in six parts of iced water is best. Of brandy 3ss. q. 3. h. is an average dose. Again this is needed in the purulent type only. For local pain, blood-letting from the cervix and ichthyol tampons 10 per cent. furnish greatest relief. The colon should be washed out daily with a quart of normal salt-solution. In most cases I allow half diet; but in the purulent type I employ an exclusive liquid diet— one ounce of beef juice every four hours and two ounces of chicken broth every four hours. These are made to alternate, at two-hour intervals. Between feedings an abundance of water, with a few drops of lemon juice to acidulate it, is given if vomiting is present.

The general treatment of pelvic peritonitis should be sustaining. Inasmuch as the effusion of lymph serves a good purpose at first, it is to be interfered with only after the causative focus of infection is cleansed. Then, for evident reasons, the effusion of lymph must be checked. If pus is present, it must be evacuated so soon as discovered.

TUBERCULAR PELVIC PERITONITIS.

I have reserved a description of tubercular pelvic peritonitis for a separate section, since its lesions differ in character from those produced by pathogenic cocci. The bacilli reach the peritoneum through either the blood or the lymphatics. It is of interest that tubercular peritonitis is not a result of a similar process in the uterus, but that the peritonitis produced through the blood is merely part of a general tuberculosis, and that