PNEUNIOCOCCUS PERITONITIS In recent years, much has been written, especially by French physicians (Netter, Brun, Broca, Comby), deseribing the type of peri tonitis in which the pneurnocoeeus of Frankel is regularly found as the sole etiological factor. The clinical picture is no new one. Already, in i842, Du ['argue described similar cases under the title of "essential peritonitis of young girls." Rilliet and Barthea mention them, as does West; and Clauderon collected in his thesis twenty-five eases (ISM). In Gerhardt's Handbuch, Rehn discussed "idiopathic rheumatic peri tonitis." In former years, lienoch observed suppurative peritonitis.
Symptoms.—According to my observations, the disease runs the following course: The onset is sudden, with vely acute symptoms, and apparently without cause. The exudation of pus is considerable, sometimes several quarts; and it tends. in the majority of cases, to eollect in the lower part of the abdomen, where it is separated from the intestinal coils and encapsulated. Left to itself, the exudate is apt to penetrate the abdominal wall through the unbilicus. In a lesser number of eases, encapsulation does not occur: and we have diffuse suppurative peritonitis.
The patients, usually girls in the middle period of childhood, are taken sick with colicky pains, conunonly located in the lower part of the abdomen, with vomiting and high fever, with which severe diarrlima is usually associated. After a few day-s, the extremely violent initial symp toms moderate. The pains become less, vomiting ceases, and the fever is less high. The loose stools, however, persist. Soon after the beginning of the disease, the abdomen becomes markedly distended (meteorism).
The next stage of the disease is characterized by a collection of fluid in the abdomen, and sets in after about fourteen days. Empyetna of th.e abdominal cavity is present. The general condition may now appear somewhat improved.
In the case of an eleven and a half year old girl, who walked to the clinic, the pus was visible through the umbilicus, and on evacuation, next clay, amounted to one and a half quarts.
On palpation, we find a tense, elastic abdomen, and often evident fluctuation. Pereussion reveals dulness, which may reach above the umbilicus. The outline of dulness in my cases was represented by a curved line, with the concavity upwards; in one case only the, dulness assumed the form of an ovarian tumor, with marked prominence below the navel. If the abscess is not opened at this stage of the disease, the
patients lose flesh rapidly, and have continued fever; while the circumfer ence of the abdomen constantly increases. The umbilicus protrudes, from the pressure of the exudate, like a hernia; the skin becomes tense; and the exudate may show through it. Spontaneous perforation through the abdominal wall may follow.* When the exudate is not rapidly walled off from the intestinal convolutions, diffuse suppurative peritonitis sets in, Mfich naturally gives a nitich more serious prognosis; but even this form may end in recovery, as the following ease, which came under my observation, shows, A twelve-y-ear-old girl, who had been delirious for sonic days, was brought into the hospital on the eighth clay of her illness. The tongue was dry and brown, the eyes hollow and circled by (lark shad ows. At the operation, nearly two quarts of thick, greenish yellow pus were evacuated. There were no adhesions. Innnediate improve ment in thc general condition resulted, ancl complete recovery followed after several weeks.
The diagnosis is difficult in the early stages. The condition is usually mistake,n for appenditicis and typhoid fever; or, in the, later stages, for tuberculous peritonitis. Important for the differential diagnosi.s are the following: In appendicitis, constipation is the rule, diarrhoea being decidedly exceptional. Tension of the abdominal wall on the diseased side is nearly always present in appendicitis; whereas in pneumococcus peritonitis it is absent or scarcely noticeable. In the early stages, the disease may easily- be confounded with typhoid fever. Such was the case with one of my patients. Severe and widespread pains in the abdomen, with protracted vomiting, speak against typhoid. The Widal reaction and the leucocyte count will help in the diagnosis. Should doubt. persist. one must carefully observe whether an exudate is present in the abdominal cavity. If the patient is first observed after pus has collected, tuberculous peritonitis may be suspected. Of great importance for our decision is the mode of onset.. Tuberculous peri tonitis rarely begins acutely, and the formation of an exudate pushing forward the, umbilicus is unlikely within such a short time. Those that are familiar with pneumococcus peritonitis will probably be able to make a diagnosis when an exudate is present, as I succeeded in doing on two occasions.