INTEA- PERITONEAL HAEMORRHAGE.* REGINALD H. FITZ, A. M., M. D., Horsey Professor of Practice, Medical Department Harvard University, Boston. u Reprinted from the Maryland Medical Journal, June l|7th, 1893. Although having accepted the compli- ment of an invitation to address your honorable body, I am, nevertheless, im- pressed with the serious nature of the task. My predecessors have often been men of such distinction in the profes- sion that success was sure to crown their efforts. Such merit as may be lacking on my part I trust may be atoned for by rny willingness to make a consid- erable personal sacrifice to be present at your meeting, A sacrifice that was not without a sense of pleasure in anticipa- tion, since it was to give me the oppor- tunity of meeting so many eminent physicians in a city which is rapidly coming to the front as one of the most important medical centres of this coun- try. It might seem fitting that one who has been familiar with the various steps which have preceded the scientific devel- opment of medical education in this country during the past twenty-one years might have something to offer on this topic. In almost any other city much might be said which would per- haps serve as criticism, encouragement or stimulation. In Baltimore, however, in the present year of grace, even an en- thusiastic advocate of the higher medi- cal education may well hold his peace. It is for your university to establish and •Annual Oration delivered before the Medical and Chirurg-io il Faculty of Maryland, April 27, 1893. 2 elaborate the model American medical school of the coming generation; as it has been the task of Harvard to faith- fully, fearlessly, but always, I hope, ju- diciously, work toward the same end during the past generation. dies. They belong legitimately to a preparatory course; not merely to the study of medicine, but to fit the youth to better undertake any professional work,to better pursue mercantile careers, to become better citizens. In this work, too, we have been obliged to seek for aid from you—our professor of pathology has long been one of your distinguished members, one who has made illustrious the name of your city and State. I can assure you that in the acquisition of Dr. Councilman we feel that a new impetus has been received to add force and breadth to our develop ment. Another of your honored repre- sentatives we have gained but to lose. In Professor Howell, our physiological department seemed to have acquired a most important addition to its strength. The lapse of a few months has shown that a wider sphere of usefulness is to be opened to him, and his future labors are to be performed where his earliest dis- tinction has been won. They are university studies; and may furnish the best possible training for some individuals to reach the highest success in whatever profession or occu- pation may be followed. It is the ap- plication of anatomy and physiology and chemistry which more exclusively be- longs to the medical school. It may be that in our own daj7 of progress these subjects are best taught as sciences where they are most needed for the prac- tical wants of mankind. But chem- istry has already become so far-reaching in its industrial possibilities that the merest elements of the science arc now required for the immediate needs of the medical practitioner. It may be questioned whether phy- siological chemistry is not, strictly speak- ing, as much of a preparatory study as is general, descriptive and analytical chemistry. Its student need have no aspirations or leanings towards a medi- cal career. He may even find a life's occupation in its pursuit, irrespective of any application of his work to the recogni- tion, prevention or treatment of disease. Pathological chemistry, on the other hand, is of the utmost importance to the physician. Without it Ins possibilities of recognizing disease, of testing the value of his measures for its relief, may he sadly handicapped. With it there are placed before him far-reaching possibili- ties in the diagnosis, prevention and treatment of disease, whose scope none of us can define. No greater encouragement can be of- fered to seekers for progress than to find themselves emulated, even if surpassed, by others whose opportunities may be larger and less restrained. However high may be the standard of the Johns Hopkins University Medical School, it can be none too high for other schools to strive for. The success of its efforts lies in the hands of such organi- zations as your honored society and of kindred societies throughout the land. The practice of medicine is the ulti- mate aim and object for which all med- ical schools must provide. However -n- -teresting the study of anatomy, physi ology and chemistry may be for then- own sake, they are'but preliminary stu- The chief end of the vast majority of! medical students is to be taught to prac- tice the various branches of medicine i and surgery. As the opportunities for de-, velopment in these directions are offered, | the student'finds himself more attracted in the one direction than in the other; and his future occupation is the more medical or the more surgical, sometimes against his wishes and despite his con- trol. He is inclined to look upon the treatment of his patient more from the medical or from the surgical point of view, as his opportunities for develop- ment have been in the one direction or in the other. This tendency is nowhere more strikingly shown than in the treat- ment of the diseases of the abdominal cavity. The frequent inefficacy of med- ical treatment, the immediate benefit often afforded by the surgeon, tend to make the physician less confident of his resources as they make the surgeon bolder in the employment of his methods. The practice of medicine thus tends, in many directions, to become more and more the practice of surgery. But a prevailing tendency is always liable to become extreme and should be guarded against. when a laparotomy might have saved life, therefore it is necessary to give the patient the chance of having life saved by this operation, although the danger is rather suggested than imminent. He is not inclined to recognize that I the benefit of the doubt may lie rather in the saving of life without an operation. The success of a successful operation is so immediate and positive that it is easy to overlook or disregard the large per- centage of recoveries under medical treat- ment from similar symptoms with all but demonstrable similar lesions. But the finding of a blood-dot after the abdomen has been opened is no necessary justifi- cation for the search for it. The ten- dency to do something when in doubt must always yield to the duty of doing what is most judicious. It seems, therefore, not unprofitable to consider the subject of intra-peritoneal haemorrhage from a general point of view, especially bearing in mind the experience of the past, with the hope that the indi- cations for its medical treatment may be made conspicuous and the existence of limitations for its surgical treatment be emphasized. In no resj ect has the progress of ab- dominal surgery led to more brilliant re- sults than in the treatment of certain varieties of intra-peritoneal hasmorrhage. After the abdomen has been opened the diagnosis is easily made and an existing or threatening haemorrhage is readily controlled. The surgeon is thus tempted by the success of his exploration in a doubtful case to forget that a surgical operation is a therapeutic necessity, not a diagnostic procedure. He reasons that be- cause persons have sometimesbled todeath In requesting your attention to this subject it is not planned to offer any new evidence, but to call to your mind conclusions, which have been previously presented, in such a form as may sug- gest that differences of opinion still exist as to the best method of treating the class of disease under consideration. To carry out this plan it is necessary to con- sider the various causes of intraperitoneal haemorrhage,their symptoms and results. The prevailing idea that intra-peritoneal haemorrhage is always a disease of women and is the result of ectopic gesta- tion has a certain practical value, but is not true. Mild and fatal cases occur in men, though in far less proportions than in women. That the haemorrhage may take place it is essential that blood-vessels rupture. The rupture demands a weak- ened vascular wall. This weakening is the result of causes which may occur in either sex alike or may be limited to the female sex. Haemorrhages from scurvy, purpura* haemophilia, infections diseases and phosphorus poisoning are without prac- tical importance in the present consider- ation. The effects of a rupture of the blood- vessels are, as Veit has conspicuously shown, essentially dependent upon the escape of blood into the open peritoneal cavity or into a part which has been sep- arated from the rest by adhesions. In the former case the blood is poured out without hindrance; more or less rapidly according to the calibre of the ruptured vessel, the size of the opening, the volume of blood and the strength of the heart. The result is a haernoperitoneum. The liquid and clotted blood lies in the lowermost parts of the abdominal cavity beneath and between the intestines. According to the extent of the haemor- rhage the haernoperitoneum either proves rapidly fatal or the blood is absorbed, except in occasional instances, without the production of a tumor. Obvious causes are the wounds which penetrate the abdominal wall or viscera from without, or which crush or tear the subjacent vessels without signs of ex- ternal lesion. The hidden causes are those which de- mand closer attention. Among these, aneurismal dilatation requires consider- ation. More common in man than in woman, abdominal aneurisms are usually irremediable. But when they affect the secondary branches of the abdominal aorta,as the smaller omental or mesenteric arteries, the timely treatment of their rupture may save a life otherwise lost. Fatal intra-peritoneal haemorrhage is no rare result of the rupture of blood-vessels in malignant tumors of the liver, pancreas and ovaries. If the haemorrhage takes place into a part of the peritoneal cavity shut olf from the rest by adhesions, a hasmatocele follows. The hsernatocele is usually pelvic in its origin and seat, occurs in the fe- male, and forms a tumor. If the bleed- ing continues, this tumor enlarges, and may subsequently rupture and produce a haernoperitoneum. If the bleeding ceases the frequent result is the absorption of the clot. But the hematocele is gener- ally seated in the pelvis, a region in which septic infectionof the clot maybe easy,and the infected clot then causes a destruc- tive inflammation of the surroundings. There are peritonitic adhesions to the walls of the rectum, vagina or bladder; and a septic peritonitis follows, or a dis- The greatest practical importance, however, is to be attached to the pelvic sources of haemorrhage. These are to be found almost exclusively in the genital organs of the female. They are the di- lated and weakened vessels in the ovaries and broad ligaments, as well as those developed in the course of a tubal or ab- normal uterine pregnancy. In this series is to be included the haemorrhagic pelvic peritonitis, almost invariably lim- ited to women and usually originating from disturbances arising in the genital tract. 5 charge of the softened clot takes place into one of the hollow organs above mentioned; oftenest into the rectum, then into the vagina, rarely into the bladder. The discharge into the rectum or vagina if properly controlled is usually harmless and beneficial; while that into the bladder is most serious, from the ex- tension of the resulting cystitis to the kidney, with the production of a pyelo- nephritis. Perforation may also take place elsewhere into the bowel, with permanent fistulas, through the ha3mato- cele, between the ileum or caecum, into the rectum. Absorption without septic infection may take place, however, and the possibility of the occurrence of the above complications is an insufficient justification for a severe operation for their prevention. | has also repeatedly made clear that there was no intra-peritoneal haemorrhage, which had been suspected. A well person, suddenly seized with rapidly advancing collapse, presentinga pinched, sunken face, an anxious and fearful expression, cold extremities, a | clammy skin, deep and sighing respira- | tion, a hollow, husky voice, an almost I imperceptible pulse, and without other objective symptoms, is, presumably, suf- I fering from a concealed haemorrhage. I Abdominal or pelvic pain is the only | positive localizing symptom, and may : not be of extreme severity or of pro- | longed intensity. Various sources of intra-abdominal haemorrhage may be ex- cluded—as the stomach, intestines, uri- nary tract or uterus—by the absence of previous symptoms pointing to disease of these organs, and by the failure of blood to appear in the vomit, stools, urine or vagina. A gastro-intestinal source of so serious a haemorrhage is usually preceded by long-continued at- tacks of pain in the region of the stom- ach or duodenum, or by symptoms of typhoid fever or of fibrous hepatitis. Metrorrhagia sufficient to produce so profound a collapse occurs only with placenta praevia or after child-birth; while renal or vesical haemorrhage, even when severe, would fail to produce so much immediate disturbance. Intra-peritoneal haemorrhages may thus be divided into those which are imme- diately or remotely dangerous and those which are comparatively harmless. The immediately dangerous are suchin virtue of the rapidly progressing anaemia. The remotely dangerous become so in conse- quence of the complications which may arise in the subsequent history of the ex- travasated blood. In the practical consideration of the individual case it first becomes necessary to establish the existence of an intra- peritoneal haemorrhage, then to deter- mine its cause and finally to decide upon its treatment. That the diagnosis is not always easy and is sometimes extremely difficult, is obvious to all who have had experience in the matter or who are familiar with the literature of the subject. An exploratory laparatomy has often proven to be the only means by which the diagnosis has been established; and The existence of a severe intra-peri- toneal haemorrhage is thus to be estab- lished by exclusion. Veit has shown that there are no physical signs suf- ficient to prove the presence of a large quantity of blood in the free peritoneal cavity. It gives rise to no more dul- ness than may result from intestinal contents; it offers no more resistance to the palpating finger than may be offered by coils of intestine. then unquestionably demanded; an imme- diate laparotomy may Ire extremely inju- dicious. The treatment of so severe an intra- peritonea) haemorrhage as that above suggested necessarily depends upon its cause. If it is due to an aneurism of the abdominal aorta, or to a cancer of the liver or pancreas, a laparatomy is useless, except, perhaps, to offer in an- aesthesia an easy means of dying. Ante- cedent symptoms are likely to have given evidence of these lesions and, fortunately, death is often so rapid from these causes that time is lacking even for anaesthesia. On the contrary, immediate laparotomy is indicated for such severe intra-peri- toneal haemorrhage when an aortic aneu- rism or a malignant abdominal tumor is to be excluded. The causes are then to be found in a small aneurism or in an ectopic gestation. The cases prose; ting the greatest difficulty in diagnosis are those where the question of treatment may best be in dispute. Debility and exhaustion are present; unexpected, perhaps, but not extreme. There is moderate pallor and tho pulse is but slightly accelerated or weakened. The abdominal or pelvic pain may be as severe and sudden as be- fore, but the constitutional disturbance is less. Such a patient may walk into the consulting room complaining of little else than pain. In this class of cases there is no considerable haemorrhage into the free peritoneal cavity, but a circum- scribed tumor will be found on pelvic examination. It is the nature of this tumor which demands most careful con- sideration. It should be determined, if possible, by other means than by an exploratory laparatomy. If this is em- ployed the treatment becomes of neces- sity abdominal and surgical, whereas in many instances it should be medical, or, if surgical, then vaginal or rectal. The former is rare, of greater fre- quency in man; the latter common and preceded by symptoms which are often sufficiently suggestive. These are the omitted menses, the irregular metror- rhagia,decidual discharge, paroxysmal or peritonitic pain, and possibly, on vaginal examination, a tumor outside of the uterus with slight enlargement of the latter. The tumor often fails, when much needed for diagnosis, from simulta- neous extrusion of the foetus and escape of blood into the abdominal cavity. Such cases are almost invariably lim- ited to women. Similar symptoms may occur in man, as in a case recently under my observation in the practice of Dr. Loring, of Newton. They proved to be due to an extensive sub-peritoneal htem- atoma from a ruptured small aneurism of the iliac artery. The pelvic tumor is to be found, at the outset, near tho uterus, usually behind or at one side. It is firm, elastic, sensitive and, when early appreciated, may be as large as an orange. Such a tumor may be a pus- tube, or an ovarian or uterine tumor, 'but thege lack the sudden development The collapse may be less profound, though still severe, and be independent of haemorrhage into the peritoneal cavity or into the hollow organs of the abdo- men. A ruptured ovarian cyst, or a tumor with a twisted pedicle, may then be concerned. In either case a tumor of sufficient size to be easily recognized will be found. An eventual laparotomy is 7 of anaemic symptoms. It may be a retro- flexed, pregnant uterus, which is to be eliminated by finding a dilated bladder and a history of urinary retention. The tumor may he due to retained menses or co pregnancy in a rudimentary horn. The tumor then forms a part of the uterus, the os being dilated and cres- centic. By way of exclusion, then, the tumor is likely to prove a haematocele or a haematoma of the broad ligament. haeraatoma is almost universally recog- nized to be expectant, that is, medical; while that of the haematocele is often in dispute. The important practical point of distinction between intra-peritoneal haemorrhage with and without a tumor is that delay is possible and desirable in the latter case; dangerous, perhaps fatal, in the former. The diagnosis of the haemorrhagic nature of the tumor often becomes con- firmed in the course of twenty-four hours by the subsequent symptoms. It is likely to become larger and eventually may even be of the size of a child’s head. It fills the pelvis, perhaps projects above it, and presses upon the bladder, rectum or pelvic nerves. Frequent micturition, painful stools, pains or pargesthesiae in the legs are likely to ensue. The vaginal wall becomes depressed behind or in front. The uterus is elevated,near the symphysis or in the hollow of the sacrum, accord- ing to the retro- or antero-iuerine seat of the tumor. Symptoms of a mild local- ized peritonitis now become apparent. There is chilliness and slight fever, the latter lasting but a few days, hypogas- tric and vaginal tenderness, which may remain for some time longer. The tu- mor tends to become smaller, denser and in the course of time, may be repre- sented merely by a diffuse induration. The larger the haematocele the more pro- longed the period of absorption and the greater the liability of the patient to discomfort from the associated adhesions, obliterated tubes, dislocated ovaries and displaced uterus, Dysmenorrhoea, ster- ility and chronic invalidism are then not unlikely results. Tiie same causes, viz., ruptured vessels in the ovaries, tubes and broad ligaments are concerned in the origin both of the haamatoma and the hgematocele. In ad- dition, the latter may be caused by an antecedent attack of pelvic peritonitis which is likely to be inferred from the previous history of the patient. The usual cause of each is to be found in an ectopic gestion, the important features in the recognition of which have already been stated. The effect upon the foetus is likely to be the same in either case. The quantity of blood poured out is usually sufficient to destroy ihe foetus if it lies between the folds of the broad ligament; and the same result is likely to follow the rupture of the sack in which the foetus is contained. In either case the haemorrhage usually takes place out- side the foetal membranes. Compression by the extravasated blood is the probable event in case of the hsematoma; extrusion of the foetus, with or without its mem- branes, is the probable event where the rupture of the maternal enveloping membrane takes place into the peritoneal cavity. Unfortunately the distinction between the turn is not always, perhaps not often, to be determined by physical examina- tion, Yet the best treatment of the In other cases it becomes increased in gise, with recurrence of the acute symp- toms. The more frequent the recur- rence, the graver the condition, the greater the danger of perforation. This may be expected to take place into the rectum when the latter becomes irritable as shown by frequent mucous discharges and tenesmus. Rectal examinations may then reveal a soft spot in the else- where hard wall of the tumor indicating the point where the discharge is to take place. In like manner a pointing of the haematocele into the vagina may be shown by a yielding, bulging mass on digital examination of this cavity. The evacuation is followed by temporary re- lief, which may become permanent with the disappearance of the tumor. On the other hand, as before stated, if in- fection from the rectum or vagina takes place, leading to putrefaction of the clot and gangrene of the wall, symptoms of peritonitis are likely to appear. But the infection of the cavity of the tumor may be rendered harmless after its oc- currence or be pervented from taking place without the need of a laparotomy. and there is the previous knowledge of a tumor, the laparotomy may be post- poned until the patient recovers from the shock due, probably, to the twisting of the pedicle of a uterine or ovarian tumor or to the rupture of a cyst. If the symptoms are less urgent and a small tumor is present the case will bear watching. The condition is likely to be a hasmatocele or a haematorna. In either event there is no urgency unless the haemorrhage persists, the tumor greatly enlarges or ruptures and a haemo-peri- toneum results, in which case there can be no question of an immediate lapa- rotomy. Frequently the extravasated blood is likely to be absorbed without serious disturbance. The patient should there- fore be treated by ice to the abdomen, rectal or vaginal enemata of cold water and by opiates for the relief of pain. Ab- solute rest, the use of the catheter and saline laxatives complete the require- ments of treatment. If as slated by G-usserow, the hsemato- cele is so large as to be mechanically disturbing or absorption ceases, or the circumstances of the patient do not per- mit slow absorption, or prolonged rest afterwards, or if the contents become in- fected as indicated by symptoms of sep- ticaemia, the tumor should be opened, emptied and drained without delay. Whether the incision should be made through the abdominal, vaginal or rectal wall must be determined in the indi- vidual case, with a general tendency in favor of vaginal drainage. In brief, the recognition of a pelvic tumor and the more accurate determina- tion of its nature in connection with the symptoms of intra-peritoneal haemor- rhage is of the greatest importance. Small and large haemorrhages into the free peritoneal cavity may occur with or without the presence of a tumor. Small haemorrhages are readily absorbed; large haemorrhages, without surgical interfer- ence, prove fatal in the course of a few hours or days and require immediate laparotomy whether a tumor is presenter not. The great success which has followed the vaginal incision, the tumor being opened and the clots removed, has been repeated so many times by so many If the symptoms are less urgent and a large tumor is present,especially if there is no history suggestive of pregnancy operators that it is unquestioned. This too, without waiting for any of the pos- sibilities which make the operation de- manded. It has often been done in the early history of the tumor, to save time in healing or to obviate possible repeated or continual haemorrhage. Healing may be even more rapid than after abdominal incision, days only elapsing between the operation and the recovery of the patient. The comparative merits of the various methods of treatment can only be determined after the lapse of time. The older statistics with reference to treatment by purely medical methods or by puncture, even by incision, are no absolute standard of what may be done now, with a better understanding/of the etiology of the condition, a surer know- ledge of the complications which may arise and a more complete appreciation of their timely prevention. The recom- mended earlyabdominal incision is not yet sufficiently proven to be without serious after-effects; in the production of hernia, or in the formation of abscesses which may lead to intestinal obstruction or may act in favor of producing a subsequent intra-peritoneal haemorrhage, from the same cause, namely, ectopic gestation. That this is no fanciful assumption has been recently illustrated in the practice of my friend. Dr. F. B. Harrington, of Boston, who has twice operated upon the same woman for intra-peritoneal haemorrhage from ectopic gestation with- in a period of two or three years. The comparative results of other treatment than laparotomy as shown by Zweifel a few years ago are as follows: Of 144 cases treated expectantly, 16.6 per cent, were fatal; 66 cases treated by puncture, 15.1 per cent, were fatal; 30 cases treated by vaginal incision, 10 per cent, were fatal. The medical treatment of intra-peri- toneal haemorrhage, when feasible, per- mits the patient to recover without operation and renders possible and easy operation when necessary, and one not demanding especial skill. Laparotomy for intra-peritoneal haem- orrhage is unnecessary in a large num- ber of cases and when undertaken sub- stitutes a severe for a simple operation, and one requiring considerable technical skill, therefore not generally applicable. In bringing these remarks to a con- clusion, I must apologize for my short- comings in presenting to you rather a medical essay than an address or oration. The last terra would have been so dis- couraging that 1 should have declined the attempt had I known it was to ap- pear under this term. Professor Welch, in extending meyour invitation, allowed me the usual license of selecting my sub- ject. I trust I may have interested you in the practical side of the ques- tion, even if I have presented it under the false colors of a dignified title.