Generally speaking, the early diagnosis of peritonitis, is based on abdominal pain, general tenderness, changes in the pulse and temperature, abdominal rigidity nausea and vomiting, distention, collapse, changes in the blood and an absence of borborygmus.

Pain in diffuse peritonitis may be so severe as to cause fatal collapse, or on the other hand, may be so slight as to be disregarded by the patient. The subjective feeling of the patient and his general appearance, in no way correspond to the severity of the local affection, but as a general rule, it gradually increases in severity, slowly or rapidly, but always by degrees, until eventually it reaches its maximum intensity. The excruciating pain that occurs suddenly in acute perforative peritonitis, is a valuable diagnostic aid. It is due to the perforation and not to the inflammation of the peritoneum. Early the whole abdomen is, as a rule, painful and tender on pressure. With few exceptions, the most severe pain and tenderness are located over the area of most marked infection. In some cases of local peritonitis, of appendiceal origin, there are marked symptoms connected with the right thigh and leg, such as violent pain, both in the sciatic and crural nerves, and any kind of movement is painful and the leg is kept flexed and adducted. These symptoms point to a retrocaecal inflammation and the flexion of the thigh, in particular, to irritation of the psoas muscle.

When an abscess develops in the retrocaecal region, there is also pain in the back and lumbar region, which becomes tender on pressure, and pain and swelling may extend even above the umbilicus.

In abscess formation, a swelling or tumor is often seen on inspection, or felt on palpation. The tumor may have sharp distinct margins or may gradually merge into the surrounding tissues. By vaginal or rectal examination, the mass may be more distinctly outlined. Percussion is also of value in outlining the area involved.

The pulse in diffuse peritonitis is always increased in rate, and diminished in volume. In the very early stages it is full and bounding. This is a very early diagnostic symptom. As the absorption increases it becomes rapid, and has a peculiar wiry character. As the body resistance is overcome by the gradually increasing toxemia, the pulse becomes irregular.

In localized peritonitis, the pulse offers nothing characteristic; its character depends upon the general conditons in each case.

Many writers attach great importance to a rapid pulse as a

sign of suppuration, perforation, or gangrene; thus, a sudden increase in the pulse to 110 and 120, which is sustained, indicates one of these conditions.

In acute diffuse peritonitis, the respiration is generally more rapid and shallow than in the local type; especially is this true in the late stages.

The temperature varies greatly, both in general and local peritonitis, and there is nothing typical about it. Some cases of circumscribed peritonitis run an afebril course in which the temperature never rises above 100 degrees. Immediately following an acute perforation, the temperature generally drops to below normal.

The abdominal rigidity, is, as a rule, more generalized in diffuse peritonitis than in the local type.

Nausea and vomiting are prominent among the early symptoms of general peritonitis. It disappears and then returns later, when it becomes very distressing. At this stage it may be explosive, but in the last stages of the disease it is nothing more than a passive regurgitation.

In circumscribed peritonitis, nausea and vomiting invariably occur early in those cases, due to intestinal origin, but it is not very frequent in other cases. The vomiting generally ceases after the onset and is seldom troublesome thereafter. Collapse sometimes occurs at the time of perforation, but otherwise it is generally a late symptom.

The distention is, as a rule, greater and more lasting in diffuse than local peritonitis.

There is still a great difference of opinion as to the value of the examination of the blood in acute obdominal conditions. The value to the surgeon would be very great if he could rely on the blood examination as a diagnostic aid in deciding doubtful cases and in determining indications for immediate operative intervention.

Formerly, in blood examinations, in acute surgical conditions, the number of leucocytes was all that was considered. The presence of inflammation or pus was indicated by an increased number of leucocytes; a leucocyte count below 10,000 meant a mild process and an extension of the infection was signified by an increasing leucocytosis.

The recent studies of Neohren show this to be incorrect and that a leucocytosis above 10,000 may mean anything from at general peritonitis to a simple inflamed appendix, or an encapsulated abscess. Therefore, the severity of the condition or the

necessity of immediate operation cannot be determined by the leucocyte count alone.

Sondern, in his valuable paper, calls attention to the great value of the differential leucocyte count as an aid to diagnosing the severity as well as the presence of intra-abdominal conditions. He says, "The increase in the relative number of polynuclear cells is an indication of the severity of the toxic absorption, and the degree of leucocytosis is an evidence of the body resistance toward infection.

"Purulent exudates were rarely, if ever, present with low polynuclear percentages, irrespective of the height of the leucocyte count, while very high polynuclear percentages almost invariably indicated their presence even if the total leucocyte count was low."

The severity of the infection is of much importance in deciding whether an operation can be delayed or whether it must be performed immediately. If the percentage of polynuclears is an index to the severity of the process it ought to be of great aid to the surgeon.

Gibson presented another phase of this subject. He calls attention to the relative disproportion of the plynuclear percentage to the total leucocytosis as being more reliable than the leucocyte count alone or the polynuclear percentage alone. He says, "This relative disproportion, is of value chiefly in indicating fairly consistently the distance of suppuration or gangrene,

the greater the disproportion the surer are the findings, and in extreme disproportion the method is practically infallible."

Noehren studied the three methods of blood examination, that is the estimation of the number of leucocytes alone, the percentages of polynuclears alone, and the relative disproportion between the two, and found the percentages of the polynuclears to be the most reliable. Not only was it the most reliable, but the question of immediate operation and severity of the abdominal condition was decided by it. He arrived at the following conclusions:

(1) Blood examination in cases of acute abdominal infections are of great value in determining the severity of the condition, and therefore, deciding whether or not immediate operative interference is indicated.

(2) The degree of leucocytosis formerly considered an important diagnostic aid, is too variable to be of any prac

tical value.

(3) The relative disproportion between the percentage of polynuclears and the degree of leucocytosis is reliable in a majority of cases, but the number of exceptions are so great that its practical value in determining immediate operation becomes very small.

(4) The estimation of the percentage of polynuclears alone is more reliable than either of the preceding methods, and therefore, together with the fact that it is the one most easily made, it is the method to be recommended.

(5) A polynuclear percentage of 90 per cent or more indicates a severe process that needs immediate operative interference; a percentage below 78 per cent means a "safe" or mild process; a percentage between the two extremes speaks for the one conditions or the other, according as it approaches the one extreme or the other.

There is nothing characteristic about the patient's general conditions as long as the process remains local, but in a well marked diffuse peritonitis the respiration is shallow. In a short time there is cyanosis, owing to the decreased aeration of the blood. As the toxemia increases the heart's action becomes weaker, and there is gradual paralysis of the vasomotor center, the capillary cyanosis increases, and we have the following picture: The face in pinched and drawn, the lips thin and blue, showing the dry, coated teeth, the tongue is dry, coated and tremulous, there is an anxious expression, the eyes are sunken, the nose sharply defined, the temples hollow, the skin lead colored, cold and parched and there is persistent nausea, and vomiting. The patient is restless and anxious and the mind is clear and active up to the late stages when there is delirium, followed by stupor and coma. In the characteristic position the patient lies on the back with the knees flexed and the thighs drawn up. The shoulders are elevated if possible. This position relieves the tension of the anterior obdominal as well as the iliopsoas muscles.

There has been much confusion on the reported cases, because of the lack of evidence in regard to the kind of peritonitis found, and the absence of bacteriological reports. Many reports are misleading, as the operations have been done on localized pus collections in the course of appendicitis, and recorded as diffuse or general peritonitis. If an infection is limited by adhesions, be they ever so delicate, it is a circumscribed peritonitis or abscess, depending upon the presence or absence of pus. A diffuse spreading peritonitis may become a circumscribed peritonitis in a few hours. An abscess may fill

over one-half of the peritontal cavity and yet be circumscribed as occurred in a case recently operated upon by Dr. Stokes and myself, in which an appediceal abscess extended from the plevis, external to the caecum and colon, to the liver. If there are no adhensions, the peritonitis is of an extending or spreading nature. This term, however, does not give any idea as to the extent of the peritonitis. There is still a difference of opinion as to the terms diffuse and general. Some writers consider the terms of identical meaning as regards the extent of the inflammation, while others use the term general for those rare cases in which the entire peritoneal surface is involved. However, this could only be determined at autopsy.

In direct perforation of the appendix into the free peritoneal cavity one can accurately estimate the time of perforation, but in the circumscribed abscess type it is difficult to say just when the abscess ruptured. In these cases the sudden increase in pain enlargement of the inflammatory zone, nausea and vomiting, interposed on an already existing clinical case of appendicitis, should be important factors in the diagnosis.

The Pathological Basis of Uterine Hemorrhage.

*BY PALMER FINDLEY, M. D., Omaha, Neb.

While it is generally recognized that hemorrhages from the uterus have an anatomical basis, they are too often looked upon as functional in their nature and without serious import.

"You are losing too much blood, but you are young and your menstrual periods are not as yet well established.”

"You are losing too much blood, but it is not long since you gave birth to your child and of course your periods are irregular."

*Read before the Nebraska State Medical Association, Lincoln, May 10-12, 1910.