As Hervieux has remarked, the appetite is often retained, but this is simply the result of "a perversion, not only of the functions of the stomach, but also of the brain." It makes no difference, however, for whatever is ingested is at once rejected.
These digestive disturbances are, we have seen, preceded by tympanites. This, indeed, is an early phenomenon, at times the initial. Curiously enough, however, the pain disappears as the tympanites and distension of the abdominal walls increase, to cease entirely when the meteorism has attained its maximum. Then even deep pressure fails to evoke sensation from this extraordinarily distended abdomen. While at the outset the pressure of a sheet caused the patient to cry out bitterly, now any pres sure is borne without complaint, and this is one of the most unfavorable prognostic signs.
This excessive abdominal distension, by pressure on the diaphragm, induces respiratory troubles, and interferes with the action of the heart and the circulation in the great vessels. The respirations become short and frequent. It is not unusual to see them rise to 40, 50, 60 a minute, and thence arises the sensation of dyspnwa, of oppression, of which, the patients complain, and the more or less cyanosed tint they present, like that of cholera patients in the algid stage. These respiratory troubles, however, are not purely mechanical. It is the rule, indeed, that women with peritonitis have also pleural and pulmonary complications, as well as cardiac affections. These complications, of course, aggravate the mechanical disturbances caused by the meteorism.
Remarkably enough the sensory disturbances are not at all proportionate to the grave state of the patients. Although at the beginning they com plain of cephalalgia, this ordinarily disappears promptly, and the intellect remains up to the end. The appearance of delirium is an unfavorable sign, and this usually is the case twelve to forty-eight hours before death. It is rather, in the majority of instances, a low muttering delirium than an active one.
Side by side with these striking symptoms of puerperal peritonitis, we must note the alterations in the face. At the outset expressive above all of pain, the facies soon becomes thin, wrinkled, and assumes the hip pocratic aspect. Later, prostration and coma deprive the face of all ex pression. Coma gradually deepens, all the faculties fade, the surface of the body becomes cold, livid.
As for the physiological phenomena of the puerperium, they are deeply disturbed The function of lactation does not become established, or else is abruptly checked if the peritonitis supervenes after its onset. Sometimes the lochia are suppressed after having been foetid. The uterus does not involute. The patient is often covered with abundant, cold, clammy perspiration, and often there appear on the thighs, genitals, and buttocks, miliary vesicles, pustules, bullce, at times petechke. Where the disease is prolonged, we may see bed-sores and gangrene of the genitals.
Course, Duration, Termination of Puerperal Peritonitis.—Only excep tionally does the inflammatory process invade at the outset the entire serous coat. Usually the hypogastric region is first affected, and only later does it reach the sub-umbilical region. At times, however, the course of
the disease is very rapid, and in a few hours the process is generalized. The patients may die in three to four days. Again, the disease breaks out violently; then, either spontaneously or as the result of treatment, there occurs a remission, to be followed by a new outburst which contin ues to the end. Again, the disease follows a more regular course, and then it may terminate in death or in recovery. If it is to be death, the course of the phenomena is somewhat as follows: A violent chill followed by intense fever with great pain and tympanites. At first limited to the hypogaztriurn, this pain quickly invades the entire abdomen, and persists for twenty-four to forty-eight hours, sometimes longer. Then appear vomiting and diarrhoea. At the end of three to four days, at the furthest, the pain ceases, but the abdomen remains greatly distended, the pulse very frequent, the temperature very high, the general condition passes from bad to worse, the traits alter, the face becomes thin and drawn, the res piration more and more painful, the vomiting ceases entirely, or else re turns but at infrequent intervals, but the diarrhea persists, the stools become involuntary, delirium sets in, followed by coma and death. But few days are requisite for the enactment of this scene, the disease rarely extending beyond the seventh or eighth day.
In more exceptional instances, the disease develops rapidly with grave symptoms, and then in about forty-eight hours the patient seems better, when on the morrow, perhaps, the disease again resumes its acute course and persists till death.
Happily such is not always the case, and in rare instances, it is true, but they are often met with in private practice, recovery ensues. Some times the peritonitis is apparently aborted, but ordinarily the course of events is as follows: After an acute stage, the symptoms decrease in vio lence, the tympanites diminishes, and an indurated mass forms in the abdomen, filling it more or less, a mass constituted by the uterus and intestines agglutinated by false membrane, and which is felt through the even as in localized peritonitis. This mass will pass through the stages which we described under pelvic peritonitis. Sometimes, and this is the rule, it gradually is absorbed to disappear completely in from three to five months; again, abscesses form which open through the ab domen, or into the rectum, bladder, or vagina.
In still rarer instances, the disease seems to transform or to merge into another, and we witness the disappearance of the abdominal symptoms, and the infection still manifests its action by the onset of suppurative arthritis, erysipelas, pleurisy, etc.
Recovery, it is seen, is always very slow, and it is not very rare to see the patients resist the first peritoneal phenomena and succumb later, worn out, as it were, by the morbid struggle they have made for so long. Such a termination is especially to be feared in cases where there is sup puration with opening into the viscera, the patients gradually yielding to hectic fever.
The differential diagnosis of metritis from peritonitis is thus usually a simple matter, and we resume the points as follows: