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•danger of infection.



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The American Practitioner and News. 463

3. Solid sterile particles are partly absorbed, and the remainder is
encapsulated without the production of peritonitis.

4. Death may be produced by general septicemia, and not peritonitis,
where large quantities of organisms are taken up by the lymph streams.

5. Peritonitis may be produced if the culture fluid is diflScult of
absorption.

6. Irritant material which destroys the tissues of the peritoneum
prepares a place for the lodgment of organisms and the starting-place
for peritonitis.

7. An infected stitch-hole tract or localized phlegmon communicat-
ing with the peritoneum forms an excellent starting-place for general
peritonitis.

8. Stagnation of degenerated fluid in dead spaces favors the growth
of organisms.

9. The presence of infected blood-clots is especially liable to cause
a virulent peritonitis.

ID. Injury to the abdominal viscera, such as strangulation of an
intestine, constriction and ligation of large areas of tissue in the
presence of pyogenic organisms, will almost certainly be followed by
peritonitis."

Mr. Lawson Tait, in a presidental address published in the British
Medical Journal, November 12, 1892, expresses in his usual style some
interesting views upon this subject. Speaking particularly of post-
operative peritonitis, he favors the idea that peritonitis is largely
dependent upon the nervous system. He believes that there is an ebb
and flow in the peritoneum, and that the great omentum is the arbiter
of these intra-peritoneal currents. In support of these ideas he men-
tions the peculiar behavior of ascites dependent upon papillomatous
disease of the peritoneum. The cause of death is the disturbance of
the ebb and flow of the serum stream of the peritoneum and the disturb-
ance of the fiinction of the liver. He believes the liver to be the lethal
organ in peritonitis. That the intra-peritoneal flow is checked is indi-
cated by two things : First, the peritoneum is dry and free from effusion
in proportion to the acuteness of the attack. The second point is the
increased quantity of biliary fluid thrown off" by the liver, as being due
to the increased quantity of fluid passed into the portal circulation by
the arrest of the intra-peritoneal flow.

The foregoing are but disconnected links in the somewhat broken
chain that represents the pathology of peritonitis. Some of these links



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464 The American Practitioner and News.

stand out in bold relief. Absorption and transudation are admitted
upon all sides, and this admission clinches the idea of certain intra-
peritoneal currents. The currents in all likelihood move toward the
diaphragm. In fact, if we take a rough glance at the anatomy of the
human subject divested of its extremities, we see the trunk in the form
of a cylinder divided into unequal halves by the diaphragm and
covered externally by a highly absorbent membrane on the outside
called the skin, and by a still more highly absorbent membrane on the
inside called the peritoneum. In fact, the absorbing capacity of the
peritoneum is such that it must be referred to as a colossal lymph sac
in order to fully grasp the meaning of peritonitis in all its details.

Treatment, In considering the treatment of peritonitis, we deem
it best to divide it into the post-operative, purulent, and specific, rather
than to employ the classification already laid down ; since we are not
always able at the time of treatment to say as positively the character
of peritonitis we are dealing with as we are after an ante- or post-
mortem section has been made. Again, the post-operative peritonitis
carries with it a clearer idea as to its causation and internal relations,
and has prophylaxis as the uppermost feature in its management. The
purulent peritonitis is generally more obscure as to its causation and
internal relations, and carries with it the idea of active interference.

The specific, or more properly speaking tubercular, since the latter
practically represents specific peritonitis, requires the proper classifica-
tion before we are able to say which cases should be subjected to and
will be benefited by an abdominal section, and which should not be
and will be hastened to their end by operative measures.

The paper of Mr. Tait, already referred to, while containing some
features that are at variance with many well-accepted ideas, is never-
theless based upon an extraordinary experience, and, coming from one
of our ablest clinicians, it merits our critical attention. The keynote
of the paper is prophylaxis during and after the operation. We all
know that while Mr. Tait does not accept Lister's teachings scientif-
ically, he does so at least practically. However, for the prophylaxis
during the operation we can obtain clearer ideas from the contribution
of Dr. Clark, already referred to in this paper. Mr. Tait considers a
thoroughly developed case of post-operative peritonitis as about as
hopeless a condition as one can possibly meet, therefore he fights it
most vigorously at its earliest onset, and prevents rather than attempt-
ing to cure. He goes on the principle that unless it is recognized in its



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The American Practitioner and News. 465

incipiency there is no need of its recognition at all, for the patient is
soon beyond redemption. He practically discards temperature and
pulse, and relies almost wholly upon the appearance of distension and
the alteration of the face. One does not need an extensive experience
in abdominal wofk to realize the uncertainty of the temperature as an
index to danger, but we doubt if Mr. Tait's disregard for the value of
the pulse as an index of trouble would meet with any considerable
support. The slightest evidence of distension in the infra-sternal
triangle is looked upon as a sign of trouble. In justice to Mr. Tait it
must be said that he expressly mentions that the appearance of disten-
sion is not necessarily conclusive evidence of peritonitis, but by con-
sidering it in that light and shaping his action accordingly, he gains
valuable ground if it should be due to a commencing peritonitis, and
would lose nothing if it were not so. In short, he is more interested in
protecting his patient than he is in verifying his suspicions.

The alteration of the face, which is of greatest importance, is not
one of pain, but one of anxiety. To use Mr. Tait's own words, ** If
she is quiet and will not talk, she is sure to get well ; if she persistently
chatters, she is sure to die ; on relief of the symptoms, which means
getting the bowels to move, the face becomes placid and the patient is
quiet." From this we are enabled to sum up the treatment of post-
oj>erative peritonitis in the following words: Excluding as much as
possible the infection and preserving as much as possible the integrity
of the peritoneum during the operation, and maintaining as much as
possible the intra-peritoneal drainage after the operation.

The first two of these three directions carries us into the conditions
underlying the infection of wounds, an immense subject in itself,
and the last means maintaining the free and unrestricted functions of
the intestinal tract.

The treatment of purulent peritonitis,*- and by this term we mean
cases of the third and fourth variety of Pawlowsky's classification, since
the cases of the first and second are too rapidly fatal to admit of any
interference, is not developed sufiSciently to formulate hard and fast
rules governing all cases. The degree of success attending the treat-
ment of these cases will always depend upon the judgment exercised
and the thoroughness with which the surgeon does his duty. Too
much stress can not be laid upon the frequent inexcusable delay in
calling in the surgeon. Frequently the surgeon's work amounts to
nothing more than an ante-mortem examination and irrigation of the

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466 The American Practitioner and News.

abdominal cavity. Operative interference must be undertaken before
the patient is in extremis, and even then a properly worded prognosis
should be expressed in order to prevent misleading ideas that constantly
arise regarding surgery in general and the operation in particular. It
is like operating for typhoid perforations — any percentage of recoveries,
however low, is a credit to surgery and a triumph for the surgeon.
The recently reported successes of McCosh, McBurney, Abbe, Van
Arsdale, and others should give encouragement to eflForts in this direc-
tion. The question upon which there seems to be a division of opinion
relates not so much as to what is to be done as to the manner of doing it.

Some favor a large, free incision with complete evisceration and the
thorough irrigation of the peritoneal cavity and the eviscerated intes-
tines with normal salt solution having the temperature of 115° P.
Others rely upon irrigation with enormous quantities of hot salt solu-
tion without evisceration. Some favor multiple incisions and the
introduction of a number of drainage-tubes or gauze, and others rely
upon one large incision. But it is self-evident that the method must
be suited to the case, rather than suiting the cases to the method.
Another mooted point is the propriety of removing the deposits of
fibrino commonly found covering the intestine. Many contend that
nature is able to cope with these, and their removal only opens up new
avenues for the entrance of infection. Some favor mopping the peri-
toneal cavity with gauze wrung from hot salt solution in preference to
cleansing by irrigation. Dr. Andrew McCosh has suggested the very
excellent idea of an intra-intestinal injection of one or two ounces of
a saturated solution of magnesium sulphate, the injection being made
into the small intestine, this being supplementary to a cleansing of the
peritoneal cavity.

Recently Van Arsdale recommended, in addition to the usual
measures for cleansing the cavity, the suturing of an incised knuckle of
intestine to the abdominal incision, the advantage being that it
aflfords an opening for the escape of gas and fecal masses, the latter
doing harm by their stagnation and putrefaction. It is also a protec-
tion against obstruction that might occur through angulation or com-
press by the drainage-tube or gauze.

According to Frederick Trevis, operation for tubercular peritonitis
is contra-indicated in the cases of general acute miliary tuberculosis ;
it has also proved to be of no avail in examples of acute miliary tuber-
culosis limited to the peritoneum. In subacute and chronic forms,



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The American Practitioner and News. 467

operation has been attended witk good results. In cases of generalized
peritonitis the best results have fbUonRPtd simple incision, without
either flushing or drainage. The cases treated by irrigation show 72.5
per cent of cures; those not irrigated show 74.3 per cent of cures.
Drainage is not necessary.

The statistics of Roersch, which present 358 operations : Of these,
j20, or 5.59 per cent, died as the result of the operation, 51 died a few
weeks later of other tubercular trouble, and 250, or 70 per cent, were
cured ; 118 were kept under observation six months or more, 79 a year,
and 53 two years longer.

lyOUISVILI^E.

2leport5 of Societies*



THE LOUISVILLE MEDICO-CHIRURQICAL SOCIETY.*

Stated Meeting, May 5, 1899, the President pro tern., John Q. Cecil, M. D.,

in the chair.

Enucleation of the Eye. Dr. T. C. Evans : On last Thursday a case
was referred to me for enucleation of the eye which presented a rather
peculiar history, with a rather trifling cause which led up to the neces-
45ity for radical treatment. The man gave the history that he was a
railroad fireman, and seven weeks ago he got a cinder in his eye. The
patient was referred to my clinic by Dr. Cheatham, stating that it was
a case for enucleation. At the time I saw the patient he was suffering
from a large abscess of the conjunctiva and also a hemorrhage into the
anterior chamber. He stated that seven weeks ago on one Monday
morning he had gotten a cinder in his eye, which had remained until
Thursday ; he went to consult the company's physician at one of the
small towns in the State, who attempted to remove the cinder and
thought he had removed it. The eye still pained him, but he did
nothing further, as he was coming to Louisville, where he lives, and
upon arrival here six days after the cinder had gotten into his eye his
wife said she could still see the cinder, and after that he waited
another twenty-four hours, making eight days, when he consulted Dr.
Cheatham. At that time an abscess had already formed in the eye.
The infection had spread almost over the entire cornea, the eye was
shrunken, and the entire anterior chamber seemed to be filled with a

^Stenographically reported for this journal by C. C Mapes, Louisville, Ky.



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468 The American Practitioner and News.

hemorrhage. Pain was violent, the man had no vision in that eye, the
eye was of no service, with no prospect of getting vision, and enuclea-
tion was indicated, not only to try and prevent sympathetic ophthalmia^
but to get rid of almost intolerable pain which kept him awake, and
this pain was not relieved by any of the usual applications.

I did not make a very close examination of the eye previous to the
enucleation, which was done last Thursday.

I mention the case simply to show that even in these trivial wounds^
which usually get well without any trouble, we sometimes see infection
take place and the eye destroyed in a short time.

Discussion. Dr. J. M. Ray : I sent the man back to Dr. Cheatham
the day that Dr. Evans enucleated the eye. Dr. Cheatham, I believe,
saw the patient first, and referred him to the Sts. Mary and Elizabeth
Hospital, where he came under my charge. When I first saw him
there was a large area of infiltration of the cornea ; the anterior chamber
was half filled with pus. I evacuated the pus in the anterior chamber;
the man became very much better for four or five days ; the anterior
chamber reformed with slight recurrence of the pus ; then the cornea
began to slough at the site of the foreign body, and he then began to
have hemorrhages into the anterior chamber. The day I referred him
back to Dr. Cheatham the corneal ulceration had perforated and the
iris prolapsed.

The history he gave me was that he had gotten a foreign body in
his eye ; that somebody had tried to get it out several days later. At one
time I was rather encouraged after I had evacuated his anterior
chamber and the anterior chamber had reformed, and I was in hopes he
was going to recover with simply an opaque cornea without adherence
of the iris ; but the area of corneal infection seemed to necrose, the
anterior chamber became obliterated, the iris fell into the rupture, and
the eye was going to the bad.

I have seen two or three cases of the kind in which eyes have been
lost from an ordinary cinder with corneal infection following. I pre-
sented one case before a meeting of the Louisville Ophthalmological
and Otological Society not long ago. Another was a man who worked
in a factory in South Louisville, and who lost his eye in the same way.

Case of Diphtheria. Dr. F. C. Wilson : I attended a case of diph-
theria some time ago, the patient being a mother with a very young
child. The question arose as to whether the child should be separated



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7 he American Practitioner and News. 469

entirely from the mother after using antitoxin as I had in the case, and
I decided to run the risk, hoping that the absorption of the antitoxin
through the milk would be suflScient to immunize the child, which I
believe it did. I injected the mother with antitoxin three times.
While the child was not kept in the room, it was taken to the mother to
be nursed at regular intervals, and I am satisfied enough antitoxin was
received through the milk to immunize it. The child was five weeks
old.

Discussion. Dr. Louis Frank : As to the question of antitoxin and
its eflFect in immunization, I doubt whether or not antitoxin can
immunize taken by the child through the milk of the mother, whether
it would be excreted in the milk, or even secreted by the mammary
gland ; again, it is questionable whether the material which immunizes
would be taken from the milk in such condition as to produce immuni-
zation in the child. I do not remember to have seen any reports of
experiments along this line, and should consider it very improbable. I
believe that the child merely escaped infection, perhaps on account of
its tender age rather than any immunity which was conferred by anti-
toxin in the milk. I would like for some of the gentlemen present
who have been using antitoxin extensively to speak upon the subject,
as it is one of considerable interest and deserves some discussion.

Dr. F. C. Wilson: It seems to me that the possibility of the milk
becoming aflfected by the antitoxin is not at all improbable. Everyone
who has had much to do with children (babies) has taken this method
of medicating them over and over again. It is well known that we can
aflfect the child by medicines given the mother. I have seen that time
and again, and do not see any reason why the child should not acquire
antitoxin, to some extent at least, through the milk, because we know
that the milk is aflfected by what is taken by the mother. We see that
in the ordinary purgatives ; every time the mother takes a purgative
the child is aflfected by it. As far as infection of the child is concerned
in this case, there was great probability of it; it was taken to the
mother regularly every two hours to be nursed, the child was in close
contact with the mother, and the probability of infection under such
circumstances is exceedingly great. The question of complete isola-
tion was a hard one for me to decide ; that is, whether to take the child
entirely away from the mother and run the risk of sustaining it by
artificial feeding, or take the chances of allowing the mother to nurse it



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470 The American Practitioner and News.

with the hope that antitoxin through the milk would be eflfective. The
latter method was determined upon, and the mother has recovered
without the child's having contracted the disease.

Dr. Wm. Bailey : The question under consideration is of consider-
able importance, as to the effect of a drug given to the mother upon the
infant. I think it depends largely upon the fact whether or not the
medicinal agent is separated from the blood by the mammary gland.
This is not the case with all drugs. I think some of the purgatives
will give a purgative action, but I doubt if every thing that the mother
takes impresses the milk. We know that in the lower animals some of
the vegetables have a deleterious effect upon the milk. For instance,
cows sometimes spoil their milk by eating weeds which are not proper
for them, etc., showing that the mammary gland separates many things
from the blood ; but I would not argue that the child had been made
immune by antitoxin given the mother because it did not have diph-
theria, for the reason that children at the breast, so young as this one,
are not liable to have diphtheria, and we should go slow in drawing
deductions from a case of this kind. It ought to be determined first
whether the milk has any antitoxin in it ; if so, then we might argue
immunity ; othewise I should doubt very much such influence being
given from the mother to the child under the circumstances related.

Dr. T. C. Evans : I have had some little experience in the use of
antitoxin in diphtheria, aild also in regard to separating those having
the disease. I have always made it a rule, although I can not say it is
a wise one, that children under one year of age are left in the house
with children who have the disease, and I have never known an infant
to have the disease under such circumstances, although I have seen
one or two cases of diphtheria in chidren under one year old. I have
never seen a case of diphtheria in a child under six months.

In regard to antitoxin immunization : After the child gets it into
the stomach you still have to run the risk of getting it absorbed as an-
titoxin. I am skeptical aboutv the effect of antitoxin when given by
the stomach. It has not been demonstrated that antitoxin is secreted
by the mammary gland from the blood, nor that the milk from a mother
who has been given antitoxin by hypodermic injection or otherwise
will produce immunity from the disease in her infant.

Another point is that all children who are exposed to diphtheria do
not take it. I have repeatedly seen one or two cases occur in a family
of five or six children where it was impossible to separate them, and no



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The American Practitioner and News. 471

other cases would develop. So it would take a large number of cases
of this kind to prove that the immunity was from antitoxin contained
in the milk of the mother.

The essay of the evening, ** The Etiology, Diagnosis, and Treat-
ment of Hepatic Abscess," was read by H. Horace Grant, A. M., M. D.
[See p. 453.]

Dtscmstan. Dr. F. C. Wilson : The most interesting case included
in Doctor Grant's series is the one where the patient coughed up some
material which is described as resembling that drawn out by the aspi-
rator. I have seen several instances of this kind where I was satisfied
that an abscess of the liver ruptured through the diaphragm, the pus
making its exit through the lung. This might have been confirmed
possibly by microscopic eximination rf)f the pus, and recognition of
liver tissue or liver cells mingled with the pus. This would have been
and important factor in confirming the diagnosis. I am satisfied that
some of these abscesses do evacuate themselves in this way. I have
seen three or four cases where I was satisfied that the expectorated
matter through the lungs had its origin in the liver. In one case it
was confirmed by the microscope. I have seen several instances where
prompt recovery followed incision and drainage of the abscess. I
have seen several instances, too, where immense abscesses were only
discovered in the post-mortem examination, and it does seem that
these cases ought not to be overlooked ; careful examination, or even
the use of the aspirator exploring needle, ought to discover the abscess
if of any size. Of course multiple abscesses may escape detection, and
these are really the most dangerous cases, simply because they are not
detected. If the abscess has continued for any length of time and has
made its way toward the surface, most likely adhesions will have
formed by the time the incision is made, then there need not be any
further delay. The course that Dr. Grant took is the one that is
safest always, inducing adhesions by packing the wound that is made
simply through the abdominal wall down to the peritoneal covering, then
allowing sufficient time for adhesions to form before completing the
operation. The ultimate result will depend very much upon the
amount of liver tissue that has been destroyed. If it is a large amount,
of course danger will be correspondingly great ; yet I have seen
several cases of abscess of the liver that recovered, although the abscess



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472 The American Practitioner and News.

contained fully a quart of pus, which means that it embraced perhaps
more than half of the substance of the liver, which had, of course,
broken down, yet recovery took place.

Dr. Louis Frank : I have seen three or four cases of abscess of the
liver, but they have all been at autopsies except one, and that one was
seen eleven years ago in the hospital here. The patient was operated
upon, and it proved to be multiple abscess, and the man died.

In listening to Dr. Grant's paper there were two or three thingfs
with which I was particularly struck, and I think Dr. Grant does him-
self and his statistics an injustice in not having made autopsies upon
the patients that died. In all those cases that died I think he would
have found multiple abscess, and that the abscess was due to infection
from other sources than the ameba coli. Where the abscess is
multiple, little is to be hoped from operative interference. It is a
question with me whether these cases should be operated upon, be-
cause we can not tell how many abscesses we have, and it means that
we must open one after another or the case will go on to a fatal ter-
mination.

Again, it would have been of interest if examination had been made



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 53 of 109)