GONOCOCCUS PERITONITIS FOLLOWING VULVOVAGINITIS Vulvovaginitis may lead to peritonitis, through extension upward of the disease. The complication is, however, comparatively rare in proportion to the very numerous blennorrhceal diseases of the vulva and vagina in young girls. Nevertheless, the contributions to the literature of this subject within recent years (Marian, Comby, Baginsky, et al.) prove that gonococcus peritonitis is no great rarity.
Experience teaches that the intensity of the inflammation varies considerably. Besides very mild cases, we encounter very severe mani festations of the disease.
The mild cases described by Marfan and Comby also begin very acutely, with vomiting, fever, and severe abdominal pains; but these subside within a few days. This is not an infrequent form of the disease, and deserves eareful attention. When the process becomes more ex tensive, with the signs of acute general peritonitis, the sensation of pain is localized chiefly in the lower part of the abclomen; so that appendi citis may be simulated and operation performed. Even the cases that present very severe symptoms—enormous abdominal clistention, very high fever, rapid anci irregular pulse, dry tongue, and extreme weak ness—may reeover without operative intervention. Zaradorsky reported seven eases, two of them with bacteriological and post-mortem findings. Two other eases, in whieh the patients died after operation, come from the Johns Hopkins Hospital. I have observed the following case: An infant a few weeks old; in miserable condition, VMS adMittO6 tO the Jenner Hospital on account of severe diarrlupa. The profuse yellowish green discharge from the genitalia contained many gono eoeei. The abdomen was meteoristic, but not tense. The eyes showed conjunctivitis and keratitis. The ehild became steadily worse, and died suddenly. At the, autopsy-, twenty to thirty centimetres of a cloudy, yellowish fluid, with numerous fibrin-flakes, were found in the lower pelvis. The peritoneal covering of the small intestines, as well
as that of the stomaeh, spleen, and liver, showed, in a few places, fibrin ous exudate. On pressure in Douglas's cul-de-sac, a considerable quantity of fibrinopurulent fluid WaS evacuated. The uterine eavity contained a little thin pus; the mucous membrane was hyperalnie; there were lie changes in the tubes and ovaries; the vaginal nmeous membrane showed hyperionia, with scattered ha-morrhages; in Doug las's poueh there were many fibrin-plaques; the intestinal eanal showed no acute inflammatory ehanges; the mucous membrane in the upper part of the small intestine was evidently thiekened. Anatomical diagnosis, gonorrLeal vaginitis and endometritis; diffuse, fibrinous, suppurative peritonitis; chronic enteritis. Gonococci Wet° present in the peritoneal exudate.
Gonococcus peritonitis, accordingly, may limit, itself to the neigh borhood of the genitalia, or may- become general. In the latter cases, one finds, either at laparotomy or at autopsy, more or less thin pus in Douglas's pouch, besides diffuse fibrinopurulent deposits. The knowl edge WC have acquired of these forms of peritonitis makes a eareful investigation of the genital organs of young girls imperative, even when the signs of peritonitis are not marked.
Gonococcus peritonitis ean easily be eonfused with appendicitis. Important for the differential diagnosis are the absence of pain at Mc Burney's point, the absence of muscular rigidity, and the presence of a vaginal discharge.
Treatment rnu6t be primarily medical, according to the principles laid down for cases of acute peritonitis. Operative intervention should be called for only in the desperate cases; for we know that even severe cases can get well without it. Nevertheless, the question of operation must be carefully considered in every case, in spite of the comparative benignity of gonococcus peritonitis. One should not wait until the patient's condition has become hopeless.