Reprinted from the Colorado Medical Journal, September, 1897. 
NERVOUS DISORDERS SIMULATING PERITONITIS. 
By S. D. HOPKINS, M. D., 
Denver, Colo. 
Lecturer and Clinical Lecturer on Nervous and Mental Diseases, University 
of Denver. 
In taking up this section of the symposium it is not necessary 
.or me to state that the diseases of the nervous system which simu- 
late peritonitis are few in number; in fact I know of no organic 
affection of the brain or spinal cord that produces symptoms simi- 
lar to those of the subject under discussion. Although in certain 
disturbances of the nerves we may have subjective and objective 
signs which may resemble the symptoms of inflammation of the 
peritoneum, yet these have characteristics which will enable one to 
come to a definite conclusion as to the nature .of the case. 
Kdantarian* says, in eight examinations of the solar and hypo- 
gastric plexus in persons who had died of acute peritonitis, changes 
which he regards as inflammatory had occurred, with subsequent 
opaque swelling of the nerve-cells, fatty degeneration and brown 
pigmentation. 
The diseases of the nervous system which resemble more 
closely peritonitis are first the functional diseases-as hysteria, and 
secondly the various forms of visceral neuroses. When we take 
into consideration the numerous manifestations of hysteria, and 
that the symptoms are excited by some slight peripheral irritation 
which may be due to vaso-motor disturbance in some of the pelvic 
organs it is not surprising that the symptoms of peritonitis may be 
produced. Simulation of acute diffused peritonitis by the hysteric 
is a rare occurrence and is only found in the most severe cases of 
f actional disease, but in women who are of a neuro-pathic temper- 
1 nt the chronic, localized, inflammatory affections are more 
closely counterfeited. 
All the symptoms of peritonitis may be present in a case of 
hysteria, but as a rule the pain of hysteria is psychical and usually 
predominates on the left side of the body p-aaad is-out-of pro-poU-i-on-- 
* Pepper's System of Medicine, Vol. li, page 113b. 2 
to the peripheric irritation in which it seems to originate, both in 
intensity and duration. It often develops and ceases like other 
hysterical symptoms, under the influence of moral impressions; is 
capable of surviving the complete subsidence of peripheric irrita- 
tion, whereas, the opposite is the case in true peritonitis. 
The locality of hysterical pain and tenderness may be the same, 
and the most irequent seat is the abdomen. A slight touch of the 
skin produces more distress than deep pressure, although, in neuro- 
pathic patients deep pressure in the left hypochondric region causes 
intense suffering. Deep pressure in true peritonitis exaggerates the 
symptoms to a greater extent than in functional disturbances. Hys- 
terical pain may begin locally, as, does the pain in true peritonitis; 
diffusing from the spot at which it first appeared into others not 
adjacent, but often connected with the first ramifications of the 
same nerve-plexus. The diffusion usually exceeds that of peri- 
tonitis, 
Vomiting is an early and troublesome symptom of inflamma- 
tion of the peritoneum, also of hysteria, although in the latter dis- 
ease the vomiting is never attended with nausea, nor does it ever 
become fecal. Immediately after the chill in peritonitis the tem- 
perature rises very high, and the subsequent elevation is moderate, 
whereas in the neurotic case the temperature is normal or but 
slightly raised, although there are cases reported where the fever 
was high, but this is probably due to some manoeuvering or pres- 
sure exerted by the tongue on the bulb of the thermometer. 
The pulse of the inflammatory affection is characteristic,in that 
it is small and wiry and in frequency out of proportion to the fever; 
in the functional affection it has not these characteristics, and in 
the majority of cases the beats per minute are normal in number; if 
they are increased the quality is full and strong. 
In peritonitis frequent micturition may be present, less often 
retention of urine and the urine is scanty and high-colored; hysteri- 
cal bladder disturbances are usual in retention and the urine is pale 
in color and plentiful. Constipation, anorexia, coated tongue and 
abdominal tympany, are common in both diseases, the latter being 
greater in peritonitis, sufficient to displace the apex beat of the 
heart, reducing the liver dullness and obliterating the splenic dul- 
ness. These symptoms may continue in hysteria until the patient 3 
presents all the symptoms of collapse or shock, but with careful 
observation and a diligent study of all the symptoms one would not 
be liable to make a mistake in diagnosis. In the pelvic forms of 
peritonitis which are generally chronic and occur in women, we 
could exclude hysteria by a careful digital examination of the pel- 
vic cavity, although we must not forget the fact that all forms of 
local inflammation may determine the occurrence or position of 
hysterical symptoms, and the two diseases may occur at the same 
time, but by carefully weighing the symptoms a correct conclusion 
can be arrived at. 
The neuralgias of the various abdominal organs may be either 
idiopathic or secondary to some organic change in the terminal 
nerves or in the viscera. Of the visceral neuroses the ones which 
are of particular interest to us and produce symptoms that may 
resemble peritonitis are gastralgia, enteralgia, ovaralgia and 
lumbo-abdominal neuralgia. In neuralgias of the viscera, the pain 
is deep seated, sometimes a dull heavy ache, sometimes of a boring 
character, rarely lancinating. 
*"It does not dart like the pain of superfical neuralgia, but 
is either constant or comes on in waves which steadily swell to a 
maximum and then die away often leaving the patient in a state of 
temporary prostration." Not only do we have this one symptom 
of pun, but general disorders accompany the different neuroses as 
they do neuralgia of the cerebro-spinal system, for one portion of 
the nervous system cannot suffer without affecting the whole ner- 
vous organism. The symptoms which accompany the visceral 
neuralgias are reflex disturbances which may be of a serious nature 
as, vomiting, indigestion, constipation, loss of appetite and marked 
emaciation. It is very common to have associated with these 
various neuroses some other affection as migraine or asthma and 
these two diseases as a rule, accompany gastralgia. 
The only form of peritonitis which gastralgia could be mis- 
taken for, is that due to perforation of the stomach; the pain in 
both being referred to the back, chest or shoulders, tenderness, dis- 
turbances in circulation, tympanitis, but in neuralgia we do not 
have any rise in temperature and the pain is unilateral, paroxysmal, 
* Pepper's System American Medicine {Putman) Vol. V, page 1215. 4 
relieved by pressure, and in some cases by taking stimulants or 
food. 
The patients do not suffer from the severe degree of shock as 
in peritonitis, although they may become prostrated and the his- 
tory of previous attacks of neuralgia in other portions of the body 
would be an important guide in making the diagnosis. 
Gowers says: "Weare not justified in regarding as enteralgia 
either vague abdominal pains, which are not increased by peris- 
taltic action or pain that occurs when the intestines are in energetic 
action, or in which there is conspicuous disturbance of the mucous 
membrane." 
The pains in enteralgia are the same as in ether neuroses; the 
two principle points of onset are the umbilicus and right iliac fossa, 
the concomitant symptoms are, distention of abdomen, hard abdomi- 
nal muscles, prostration and severe collapse and the various other 
reflex phenomena which have been stated above. 
In acute diffused peritonitis the pain may begin locally but 
soon becomes diffused, and is increased by pressure; the nausea, 
vomiting, distended abdomen and collapse are more or less con- 
tinuous and have a protracted course. 
In the majority of cases of neuralgia the patient is either a vic- 
tim of hysteria or is suffering from anemia and especially in the 
visceral neuralgias we are aware that the pains occur at the time 
when the organ is performing its function. This is particularly the 
case in ovoralgia,and is not strange when we recall the fact that the 
ovarian nerves terminate i i the blood-vessels and the consequent 
effect of any irritation is a dilitation of the vessels or a hyperaemia 
of the organs, which causes pain, localized tenderness and various 
other reflex phenomena that may be found in peritonitis. A care- 
ful digital examination would prevent an error. 
It is not unusual to have abdominal pain that cannot be re- 
ferred to the abdominal organs, which has no relation to the time 
of functional activity of the same. This pain is probably due to 
some disturbance of the sympathetic system of nerves. Pain is 
diffused, with paroxysms of exaggeration and is not increased by 
pressure, and its position is either above or below the umbilicus. 
The absence of other constitutional symptoms would exclude 
peritonitis.