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BY R. M. SIMON, M.D.,
PHYSICIAN TO THE BIRMINGHAM GENERAL HOSPITAL.
It would scarcely be possible in the twenty minutes allotted by the laws of the Society to readers of papers to do more than glance at some of the prominent facts and difficulties of the subject and suggest certain points for discussion. The recentlypublished papers by Dr. Gee and Mr. Tait would seem to have rendered it a work of supererogation to bring the subject of Peritonitis before this meeting, but it is perhaps well to discuss it while our minds are full of attention and our interest excited. My best excuse however is, that I find the disease so interesting, and the responsibility of its treatment so great, that I cannot but hope to gain from the experience of the members present.
The aspects in which I specially wish to regard peritonitis are as it occurs, 1, in tuberculosis; 2, typhoid fever; 3, as the result of perforation of any hollow viscus; 4, and finally, or what is practically from the first, general purulent peritonitis.
There is a general consensus of opinion that while the distinctive signs of the disease are pain, tenderness, and distension associated with fever, rapidity of pulse, and the facies Hippocratica, the diagnosis is often nevertheless extremely difficult. A very intense degree of peritonitis may exist without fever, without much pain, and with but little distension. Of such a nature was the case already recorded by my friend Mr. Barling and myself, where six hours after a perforation of a gastric ulcer an intense and general peritonitis was found on operation, though there had been no distension; and it had been specially noted that superficial palpation caused no pain, which was only complained of when a more thorough examination was made. The
* A paper read at the meeting of the Birmingham and Midland Counties Branch of the British Medical Association, December, 1892.
temperature, as in many other similar cases, was not raised, but the pulse became rapid and wiry, and the condition of collapse more marked than before. Operation was determined upon.
In connection with this apyrexia, it is a very common fact that we never seem to get quite so high a degree of fever in peritonitis as in most other inflammatory lesions.
A little girl (M. H.) I saw in consultation and sent into the hospital for operation had never a temperature of more than 102°, although we found her abdomen quite full of pus. Her temperature was never so high as in the case of H. H., a patient of mine in the General who suffered from tubercular peritonitis, and whose abdomen was opened by Mr. Barling with marked relief of the pain and discomfort and a satisfactory reduction of temperature. The peritonitis was nothing like so acute as in the other little girl, and very little pus was present.
Pain is a very variable symptom indeed, and one on which very little reliance can be placed. We have all seen rapidly fatal cases in which less pain was complained of than in many cases of colic; and only a month ago I had under my charge a girl who was sent into the hospital for peritonitis on account of the great pain she complained of in the abdomen. Her tem
perature was 101°, and it certainly looked like a case of peritonitis. She was found to have a blue line on the gums, and, as it turned out, was suffering only from lead colic. The pain, on the other hand, may be agonising.
The most important sign of the disease, and the one on which most reliance can be placed, is the distension of the intestines, meteorosis; although this, like the other sign, is not infallible, as evidenced by cases that occurred during the epidemic of influenza last year.
The facies Hippocratica associated with abdominal pain and tenderness is, perhaps, the least variable sign of a bad case of peritonitis, and should excite our apprehension, and incite us to renewed efforts for finding the cause of the disease. But, indeed, there is no pathognomic symptom; and it is only the grouping of those we have discussed that justifies the diagnosis
of the disease. Of course, if there be any condition favouring the development of peritonitis, such as an operation, or the existence of a hernia which has become strangulated, the diagnosis is very easy; but the difficulty lies in those cases where no such cause is at hand; and it is precisely in these that a correct diagnosis so often means saving a life which, for lack of it, may be lost.
I was taught that no case of peritonitis was idiopathic—that it was always secondary to some forms of mischief which ought to be discovered; and yet it was said that it might occur without obvious cause—or, indeed, ascertainable reason--in Bright's disease; and now the popular voice is raised in favour of the microbic theory of causation and the ever-present foces micrococcus. To me it seems that in the present, as in the past, this explanation is unsatisfactory; and it would be easy to give instances in which, so far as human skill can determine, no micro-organism can have had access to the cavity, though a rapidly-increasing purulent peritonitis has taken place. Of such a nature was the case of a child (M. P.) I saw with a suppurating abnormal cyst of the urachus. The intestines were separated from this cyst by a normal peritoneum, and no glands were present to be infected by the intestinal catarrh and so start the disease. I feel strongly that one has more right to state boldly that the disease may exist without a causative micrococcus than have those who accept the newest fashionable theory of medicine to demand an unquestioning belief in its omnipotence. On them, at any rate, should the onus probandi rest. I would not under-rate-I could not over-rate-the enormous value of Koch's discovery of the tubercle bacillus, and the impetus he has given to bacteriology; but I do strongly deprecate the allimportance of the rôle which is attributed to this and other pathogenic germs. Clinical medicine can never rest on a microscopic basis, and it will be fatal to progress if we come to be satisfied with such.
It is, of course, undoubted that a great majority of cases of peritonitis start from a neighbouring purulent or inflamed focus, such as a typhoid or tubercular ulcer, or from suppuration in a Fallopian tube; but just as in empyema-which, so far as we know, often occurs without the slightest evidence of suppuration elsewhere-so may it be in peritonitis, as in the cases of the little girls M. P. and M. H.; and a fluid effusion in the abdomen may be purulent from the first, not associated in its beginning with pus elsewhere, or if treated secundum artem at any period in its course.
I must state my very strong inclination to believe in the importance of the rôle played by the nervous system in the development and course of the disease, though no doubt this is to a large extent the substitution of one unknown quantity for another, and I am sure that upon the condition of the nervous system the prognosis very largely depends.
No patient dies, so far as I know, because a larger or smaller quantity of pus happens to be in the peritoneal cavity; and I believe that, given no persisting cause for suppuration such as an open gastric or intestinal ulcer, no patient need die if the pus be removed before adhesive or destructive inflammation has interfered with the mechanics of digestive processes.
On the other hand, it is quite certain that a patient may die very early in the course of a case, before the suppuration has weakened or the fever has exhausted. The most fatal cases are those in which the temperature may have been subnormal from the first, as in two cases of perforated gastric ulcer I have seen. They died, one in thirty hours, the other within four days of the rupture which determined the peritonitis, and the extent of this was not half so great as in the case of M. H.. nor was the amount of the pus anything like so large. They died of shock, but no doubt would have recovered from it if it had been possible to prevent the persistence of the shock by removing the peritonitis and its cause. In neither of these cases however was the shock so intense, or the conditions so alarming as in Mary W., a woman who was admitted during the influenza
epidemic into the General Hospital under my charge on May 21st, 1891. She vomited over-night, and took two pills to relieve constipation. Next morning her bowels were moved at eight o'clock. Immediately afterwards she fainted, and was brought to the hospital on account of most alarming collapse. Her face was blanched, her lips bluish-white, her pulse scarcely to be felt; her respirations were infrequent and sighing, and the temperature was 96 3°. The abdomen was tympanitic, distended and tender, and great gastric pain was complained of.
Had this case occurred subsequently to that of the perforated gastric ulcer I should have had no doubt that I had a similar one to deal with, and advised operation to give a chance of life. Her condition was so urgent that I thought it advisable to give her the chance of rallying before considering other treatment, and under the influence of warmth, rest, and stimulation, she recovered.
Surely this was a case in which the stress of the mischief, probably the influenzal poison, was upon the sympathetic nerves. in the abdomen, and yet the symptoms were entirely those of peritonitis. Such a case would at least justify my warning, in opposition to some who speak of the ease of diagnosis of perforation and peritonitis, that the difficulty may be great and the need of caution important.
A similar case was that of E. K., who was admitted into hospital four days later. That morning, while at work, he had
fainted, after complaining of great pain in the abdomen. was admitted in a state of great collapse, surface cold. pulse scarcely to be felt, respirations sighing (seven or eight to the minute), and temperature sub-normal. His abdomen was distended, and the pain and abdominal tenderness persisted for two days; but he left the hospital in four days more quite well, the temperature having never exceeded 99°.
In connection with these cases, and bearing on the influence of the nervous system in the causation of the disease, it is interesting to quote the remarks of Dr. Err on what he calls lipothymia without abdominal signs.