[Reprinted from the American Gynecological and Obstetrical Journal for May, 1895.] ACUTE LOCALIZED VS. DIFFUSE PERITONITIS IN WOMEN FROM A CLINICAL STANDPOINT* By Henry C. Coe, M. I). It seems as if the enormous increase in medical literature were sometimes a hindrance rather than a help to us in the practical appli- cation of the fundamental principles of our science. In the days when we depended more on our own experience and observation, and less on the contradictory teachings of the last new books, our rules of dif- ferential diagnosis were more clearly defined, and we were less liable to overlook probable conditions while seeking for those which are only possible. This comment applies particularly to gynaecology, which branch of medicine, more than any other, has suffered from an excess of literature. The changes which have been rung on every theme have served to confuse specialists themselves. When every society discussion develops such radical differences of opinion between emi- nent authorities, it is not surprising that the general practitioner is apt to infer that the whole subject of diseases of women is in a process of transition and that few questions have been positively settled. One result of the aggressive tendency of gynaecology must strike every consultant-what may be called the surgical education of the prac- titioner, so that in a consultation it is often the latter rather than the former who first suggests the advisability of operative interference. While from one point of view this progressive tendency is to be commended and has undoubtedly resulted in the saving of many lives which were formerly sacrificed to timidity and unwise confidence in Nature, from another it would appear as if the general practitioner were in danger of forgetting that there are still a considerable pro- portion of pelvic affections which do not require the aid of ti e surgeon for their relief. This somewhat prolix introduction is intended as an excuse for presenting a subject which has been discussed so often that it * Read before the New York County Medical Society, March 25, 1895. Copyright, 1895, by J. D. Emmet and A. H. Buckmaster. 2 Henry C. Coe, M. D. seems almost threadbare. But, in my experience it is still necessary to rid our minds of the confusing details which have been added to the original clinical picture of peritonitis and to formulate certain rules for our guidance at the bedside-a place where theories must always give place to facts. When we see practitioners of more than average intelligence, if confronted with an ordinary case of pelvic suppuration, oppressed with the bugbear of impending rupture of a pyosalpinx into the general peritoneal cavity (an accident so rare that few of us have seen more than two or three cases), and find that it seems to be the prevailing impression that the presence of tympanites associated with abdominal pain, a rapid pulse, and elevation of tem- perature, necessitates the giving of a gloomy prognosis, we are led to ask whether we have improved very much upon our predecessors; who unfortunately had so much more practical experience with the medi- cal treatment of peritonitis than we. I think that we can still'find profitable matter for discussion in this familiar theme. It is unneces- sary to rehearse the characteristic symptoms presented by virulent general peritonitis, such, for example, as follows the rupture of an ovarian or appendiceal abscess, and terminates fatally in four or five days, since the question of differential diagnosis does not arise in such cases, but in those which, as Thomas has remarked, " may run their fearful course with the greatest obscurity, so as to mislead the most careful diagnostician, even up to their latest stages." A careful review of the history is all-important, since the overlooking or misin- terpretation of facts which may appear to be of minor importance often leads to an erroneous theory, which the symptoms are made to support. Thus the fact that a patient has had one or more previous attacks should at once lead to the suspicion of a purely local trouble. The existence of a previous affection of the annexa is not always easy to determine from the patient's statements. The difficulty of diagnos- ing appendicitis from salpingitis in the female is well known, also the frequency with which these conditions co-exist. Even in puerperal cases one must constantly bear in mind the possibility of the.appendi- ceal origin of a peritonitis which appears to be secondary to infection of the genital tract. On the other hand, many cases of ovarian and true pelvic abscess have been incised in the region of the appendix under the impression that the latter was the origin of the suppuration. But, whatever may be the starting point, it is important to establish the fact that at some time in the history of the case the pain and ten- derness were localized. This is all the more important because after the patient has been drugged with opium for several days, one who Acute Localized vs. Diffuse Peritonitis in Women. 3 sees her for the first time finds it difficult to bring out this point clearly. The original condition is then masked, while the rapid, hard pulse, high temperature, persistent vomiting, tympanites, and pinched, anxious facies, lead the attendant to believe that even if it was origi- nally localized, it has now become merged in a general peritonitis. In his anxiety to render the patient comfortable, he has not only made her worse, and added to his own anxiety, but has lost the clew to the diagnosis. The length of time during which the symptoms have continued is an important point which we too often overlook. The fact that they have persisted for several days without becoming pro- gressively worse should, even in the absence of other data, lead to the inference that the trouble is localized. When the characteristic thermometric variations, sweating, etc., which indicate suppuration, develop, the diagnosis is clearer, though this may not take place until quite late. The difficulty in locating the septic focus in cases of puerperal infection has been experienced by all of us. Thanks to prompt and intelligent interference, general peritonitis of puerperal origin is now extremely rare, at least in women under the care of physicians. In modern lying-in institutions it is practically unknown. Any attempt to establish a positive differential diagnosis between general and localized peritonitis from an analysis of individual symp- toms would be most unscientific; indeed the common source of diag- nostic errors in all abdominal affections is the effort to base an opin- ion on symptom, or group of symptoms, which are supposed to be characteristic. Can we place any dependence on the classical " rapid, wiry pulse " of diffuse peritonitis? Who has not observed it in the ordinary pelvic variety ? As for the temperature (except in the fatal cases), we must admit that a recent writer expresses the general be- lief when he says that " for him who implicitly trusts to the revelations of the thermometer in this affection it will prove an unreliable guide." And yet how often are we plunged into the depths of despair by a temperature of 104° or 105° and on the other hand are disposed to think that all danger is over when it falls to 100° ! We are dis- turbed by the presence of general abdominal pain and tenderness in one case, and in another lull ourselves into a state of over-confidence by their entire absence, forgetting that the apparent comfort of the patient may really be that fatal apathy which heralds the approach of death. Vomiting in a typical case of diffuse septic peritonitis is certainly a characteristic symptom, but it is by no means always present, even in fatal cases, until just before death, in a patient who has been care- 4 Henry C. Coe, M. D. fully handled. On the other hand, persistent vomitins; is not infre- quently present in cases of localized trouble, where unwise attempts at feeding and medication (especially the excessive use of opium) keep the stomach in an irritable condition. Tympanites is no longer regarded as pathognomonic of general peritonitis (excluding the ex- treme form seen in rapidly fatal cases), though it always causes some uneasiness. It is often excessive, even in pelvic peritonitis, though it is not apt to be either persistent or so well marked about the um- bilical region, neither are the peristaltic movements of the intestines limited or absent, unless as the result of hyper-medication. 1 have not referred to constipation, because I believe that altogether too much stress has been laid upon its importance in connection with prognosis. The abdominal surgeons have been responsible for this erroneous interpretation. It is only after one has seen patients die of post-operative peritonitis on the seventh or eighth day, after hav- ing had daily evacuations of the bowels, and others make a good recovery who do not respond to laxatives and enemata for five or six days, that he begins to believe that too much stress has been laid on this point. Now with reference to the much-vexed question of early purga- tion versus the use of opium in the treatment of peritonitis, I shall only observe that the advantages of both methods have been repeat- edly set forth by their adherents, often in language which showed in- temperate zeal rather than calm discrimination. As in many other instances, facts have been adjusted to theories. When we hear a man arguing that the death of a patient after an abdominal operation was due to the fact that she received two or three small injections of mor- phine, or that her bowels were not moved on the routine third day, I infer that he is trying to excuse his own errors in technique, per- haps at the expense of the gentleman who assumed the after-treat- ment of the case. The seductive theory that intraperitoneal sepsis can be eliminated through the intestinal tract is no more susceptible of universal application than is the old teaching that opium is the sheet-anchor in all cases of peritonitis. The temporary amelioration of symptoms observed in cases which nevertheless go on to a fatal termination, either after free purgation or when the pain, vomiting, and restlessness are controlled by the moderate use of opium, are equally misleading. I have no intention of entering into a discus- sion of this question, and would merely state my belief that the profession will so far overcome that horror of opium in the treatment of peritonitis, due to the influence of abdominal surgeons, that thereby Acute Localized vs. Diffuse Peritonitis in Women. 5 will be used in moderation for the relief of pain, at the same time that intestinal peristalsis is maintained by the judicious administration of laxatives. Personally I have long regarded the action of laxatives as a useful aid to diagnosis. When a persistent amelioration of all the unfavorable symptoms is noted in a case in which the diagnosis be- tween diffuse and localized peritonitis is doubtful, I have usually felt justified in inferring that the latter condition was present and in giving a favorable prognosis. If the improvement was only tempo- rary, and there was a rapid return of the pain, vomiting, tympanites, and anxious facies, I have assumed that probably no amount of purga- tion would save the patient. And so with the application of cold and the administration of antipyretics, as in the old heroic age of medi- cine. Those of us who used the Kibbee cot and ice coil so religiously were impressed with the fact that in the fatal cases of septic peritoni- tis after ovariotomy the fever was only controlled (when it was at all) by the persistent application of cold, whereas in the cases of localized inflammation (which we then distinguished from the former by call- ing them " traumatic," because the patients recovered) the fever was not only easily controlled, but the temperature remained lower for several hours after the treatment was suspended. In other words, the behavior of a patient when an ice bag is applied to the abdomen may furnish a valuable clew to the seriousness of her condition. It is not, then, from the presence of any striking symptom, or symptoms, that one arrives at a decision in a doubtful case. It is the whole picture which we must study, not a few isolated details which stand out in bolder relief than others. To the experienced eye the "look" of a patient with fatal septic peritonitis is rarely misleading. It is just as impossible to describe this as it is to describe the peculiar sensation imparted to the examining finger by commencing epithelio- ma of the cervix uteri. Nine men who have only read graphic de- scriptions of the latter will entirely overlook it, while the tenth, who has forgotten the descriptions, but has learned to recognize the disease itself by actual experience, will at once detect it. The facies of a patient with localized peritonitis (no matter how severe the symp- toms) is certainly quite different from that of one in whom the in- flammation has become general. The detection of the shades of dif- ference is entirely a matter of personal experience and observation. I would not be understood as vaunting this as a peculiar gift possessed only by a chosen few, nor would I have you think that I approve of "snap" diagnoses, made by a glance at the patient. But I leave it to those who were hospital internes ten years or more ago, when sep- 6 Henry C. Coe, M. D. tic peritonitis was so common and so fatal, if I am not right in affirm- ing that the facies of the patient alone often justifies us in giving a favorable or gloomy prognosis aside from all the other symptoms. I shall merely refer to the physical examination, for I assume that we are all familiar with the condition found in ordinary cases of localized peritonitis, of pelvic or appendiceal origin, when it has not been masked by complications, such as pregnancy, tympanites, hysteria, etc. In many cases we must be prepired to derive little or no in- formation from the examination as to the origin of the trouble. The pelvis may be so filled with exudate that it is impossible to map out any organ, or to affirm that the annexa on one side are more diseased than on the other. The patient may no longer be in a condition to locate the seat of greatest tenderness, or general hyperaesthesia may prevent the examiner from comparing the two sides. Under these circumstances high enemata are often of great service, since the re- sulting diminution of tension allows him to make deeper pressure. If the question of operative interference has been raised, the aid of anaesthesia may be necessary. There is one factor in cases of pelvic peritonitis which we often overlook. I refer to the hysterical element. As Osler has said, " it has deceived the very elect." I recently saw in consultation a youftg woman whose condition was judged by an esteemed colleague to be so serious that an early resort to abdominal section might be necessary. He had been misled by the statements of the attendant with regard to the normal condition of the patient. Septic infection after an early abortion was followed by general abdominal pain, con- stant vomiting, excessive tympanites, elevation of temperature to 103°, and a pulse which averaged 130. She was apparently delirious. A brief review of the history developed the fact that the patient was hysterical and prone to exaggerate her symptoms. She had been placed under the influence of morphine at the outset, the bowels hav- ing been locked up, and was simply suffering from the effects of the drug, plus hysteria. Her facies alone was not that of a patient with general peritonitis, and I felt justified in predicting that if medica- tion and attempts at feeding were suspended and a high enema was given, there would soon be a change in the situation-which was fully justified by the result. This is a typical case such as one often sees in consultation. It is obvious how important it is in private practice to recognize the harmless character of the condition before throwing a family into the deepest distress by hinting at the necessity of a formidable operation. Acute Localized vs. Diffuse Peritonitis in IVomen. 7 Aside from the question of prognosis, which is so important to the patient and her friends, the general practitioner, who has the laudable desire to leave nothing untried in order to save his patient, naturally asks in every case of peritonitis : " Ought I to call in a surgeon, and if so, when ? " Now his decision, as well as that of the surgeon himself, must be affected by a variety of considerations which do not obtain in hospital practice. This is an important difference which has not been sufficiently emphasized. We report in societies various experi- mental operations, more or less successful, and doubtless legitimate in their place, but are we prepared to perform them on Fifth Avenue as promptly as on Avenue A, or in our hospitals ? Have we yet reached the stage when we would advise and perform symphysiotomy, hyste- rectomy for suppurative disease, or any other novel and ingenious operation which we have done so successfully in the clinic ? I think not, as yet. When we refer to abdominal section for acute general peritonitis, let us understand then that it is still a hospital operation -a desperate remedy for a desperate condition. From an experience of several years in the deadhouse, in which probably nine-tenths of the autopsies were performed cn patients dy- ing of post-operative peritonitis, as well as from my subsequent ex- perience at the operating table, I have become quite pessimistic re- garding the cure of acute diffuse peritonitis by coeliotomy. Undoubted cases, especially those of appendiceal origin, have been operated upon successfully, but from a careful study of the majority of those re- ported, one must infer that the inflammation was localized, the exu- date extending perhaps over half of the abdominal cavity, but still localized, and of course subject to the same treatment as any other abscess. When we speak of abdominal section for diffuse peritonitis, that is an entirely different matter; and when we advise it in private practice let it be with a full understanding on the part of the attend- ing physician and friends that recovery, even after the most thorough breaking up of adhesions, evacuation of pus, irrigation and drainage, is to be regarded as little short of a miracle. But it is in the localized cases that we find the legitimate field for operative interference and here the results have been so brilliant (es- pecially in appendicitis) that one can readily understand how every case of circumscribed peritonitis should be looked upon as having a possible surgical conclusion. While acute pelvic peritonitis is no longer regarded as a disease per se, but simply as a result or complication of tubal or ovarian trouble, it is rarely that we feel justified (in private practice at least) in 8 Henry C. Coe, M. D. dealing in a radical manner with the latter during the height of the attack. Having determined that he has to do with a circumscribed process, which seems to be in no danger of becoming general, it seems wiser for the surgeon not to interfere until he can definitely locate a pus focus, or at least feels reasonably sure from the symptoms that one exists in the pelvis. The vaginal route offers such safe and easy access that we do not hesitate to resort to explorative puncture and incision without waiting for that well-marked bulging and fluctuation which used to mark a pelvic abscess as " ripe " for operation. Remembering, however, that many patients have repeated attacks of pelvic peritoni- tis, in whose tubes we afterward find no pus, it does not follow that one should advise an exploration simply because a small mass is de- tected behind the uterus with a persistent elevation of temperature. Boldness is commendable when tempered with judgment. It is in these cases that delay may be safely advised, but of course not in those in which the presence of an induration in the flank clearly indi- cates the propriety of a direct incision. The evacuation of even a small quantity of pus per vaginam sometimes effects a remarkable amelio- ration of symptoms, which were so serious as to cause much un- easiness. But it is unnecessary to dwell upon details that are so familiar. My object has been, not so much to lead up to the surgical treatment of pelvic suppuration, as to provoke a discussion from the standpoint of the general practitioner of a subject which, though suf- ficiently familiar theoretically to us all, can hardly be said to have been completely mastered even by the most experienced.