Classification of Acute Peritonitis.*

BY N. SENN, M. D., OF CHICAGO.

Acute inflammation of the peritoneum is produced by so many different causes and assumes such varied clinical aspects that it is extremely difficult to formulate a satisfactory classification of the condition. A discussion of its etiology, differential diagnosis, prognosis and treatment, except upon the basis of a clear and comprehensive classification, is fruitless and misleading, and usually results in the deduction of erroneous and often dangerous conclusions. The classification should include the anatomy, pathology and etiology of the disease to be of value in rendering a correct diagnosis and a reliable prognosis, and to enable the physician and surgeon to advise and apply effective therapeutic meas

I. ANATOMIC CLASSIFICATION.

An accurate anatomic diagnosis is necessary for the purpose of locating the inflammatory process correctly or to trace the connection between it and the organ primarily the seat of infection. During the beginning of the attack and in cases of localized peritonitis, the inflammation can usually be located without much difficulty, while the reverse is often the case after the disease has become diffuse. The inflammation may commence and spread from either surface of the serous membrane, visceral and parietal.

a. Ectoperitonitis.-An inflammation of the attached side of the peritoneum is called ectoperitonitis. As compared with inflammation of the serous surface, this inflammation of the subendothelial vascular connective tissue is characterized clinically and pathologically by intrinsic tendencies to limitation of the inflammatory process. In infected wounds of any part of the abdominal wall in which the peritoneum is exposed but not perforated, the primary ectoperitonitis is occasionally followed by the extension of the infection to the serous surface through the lymphatics, or by the direct extension of the infective process through the tissues until it reaches the endothelial lining. Peritonitis of a visceral origin is always preceded by ectoperitonitis, whether the infection reaches the peritoneal cavity through a perforation or by aggressive extension of the infection from a primary focus through the tissues until it reaches the free peritoneal surface.

b. Endoperitonitis.-What

is usually

Abstract of a paper read at the Fourth Triennial Congress of American Physicians and Surgeons, Washington, D. C., May 5, 1897.

inflammation of the serous surface of the peritoneum, which, anatomically speaking, is an endoperitonitis.

C. Parietal Peritonitis.-Inflammation of the serous lining of the peritoneal cavity is called parietal peritonitis. It may occur as a primary affection in penetrating wounds of the abdomen, but more frequently is met with as a secondary disease in consequence of the extension of an infection from one of the abdominal or pelvic viscera, or perforation into the peritoneal cavity of a visceral ulcer or a subserous or visceral abscess.

d. Visceral Peritonitis.-Inflammation of the peritoneal investment of any of the abdominal or pelvic organs is known as visceral peritonitis. The inflammatory process is seldom limited to a single organ, as during the course of the disease adjacent organs or the parietal peritoneum will surely become involved. In diffuse peritonitis the whole peritoneal sac and the serous covering of all the abdominal organs is affected. The nomenclature of visceral peritonitis is a lengthy one, as it includes all of the abdominal and pelvic organs which, when the seat of a suppurative inflammation, may become the primary starting point of an attack of localized or diffuse peritonitis.

Pelvic Peritonitis.-Inflammation limited to the peritoneal lining of the pelvis and its contents is known clinically and anatomically as pelvic peritonitis. It is an affection almost entirely limited to the female sex, and in the majority of cases is caused by extension of gonorrhoeal infection from the Fallopian tubes or a mild form of pyogenic infection from the uterus, its adnexa, or the connective tissue of the parametrium.

f. Diaphragmatic Peritonitis.-Inflammation of the under surface of the diaphragm is described as diaphragmatic peritonitis, and when it assumes a suppurative type and remains limited, leads to the formation of a subdiaphragmatic abscess. This acute localized form of peritonitis is usually secondary to suppurative affections of the liver and gallbladder, and perforating ulcers of the stomach and duodenum.

2. ETIOLOGIC CLASSIFICATION.

The classification of peritonitis upon an etiologic basis is of the greatest importance and practical value. The nature of the exciting cause frequently determines the anatomic and pathologic varieties. It likewise has a strong bearing upon the prognosis, and often furnishes positive indications as to the methods of treatment which should be adopted. Peritonitis, like every other inflammatory affection, is always the result of infection with pathogenic microbes, usually of the pyogenic variety. The etiology must consider the dif

ferent avenues through which the microbes find their way into the peritoneal cavity.

Traumatic Peritonitis.-Primary peritonitis has usually a traumatic origin; that is, the injury establishes a communication between the peritoneal cavity and the surface of the body or some of the hollow abdominal or pelvic organs, through which pyogenic bacteria enter in sufficient quantity and adequate virulence to cause an acute inflammation.

b. Idiopathic Peritonitis.-The occurrence of peritonitis without an antecedent injury or suppurative lesion is doubted by many. It is too early to deny in toto the existence of so-called idiopathic peritonitis, but future bacteriologic examinations of the inflammatory product will no doubt reveal a microbic cause in all such cases. As an isolated affection, peritonitis is found most frequently in females. during or soon after menstruation. It is probable that the pyogenic bacteria multiply in the blood which accumulates in the uterus and reach the peritoneal cavity through the Fallopian tubes. It is said to have occurred in consequence of exposure to cold, and is then known as rheumatic peritonitis. Occasionally

it has been observed as one of the remote

manifestations of Bright's disease, pyæmia and the acute eruptive fevers.

C.

Perforative Peritonitis.-Perforation of an ulcer of any part of the gastro-intestinal canal, or of an abscess of any of the abdominal or pelvic organs, or of the abdominal wall into the peritoneal cavity, is by far the most frequent cause of acute peritonitis. Two important and frequent causes are appendicitis and suppurative salpingitis.

d. Metastatic Peritonitis.-This form of peritonitis occurs, like other metastatic affections, in connection with suppurative or infectious processes not connected with the peritoneum. In very rare cases it develops in the course of many of the acute infectious diseases, as scarlatina, smallpox, erysipelas, rubeola, and even varicella. It also occurs frequently in the course of septicemia and pyæmia.

Puerperal Peritonitis.-Peritonitis occurring in connection with septic diseases of the puerperal uterus has for a long time been known as puerperal peritonitis. The infection may extend from the endometrium through the Fallopian tubes, or it may follow the lymph channels or the thrombosed infected uterine veins. Infection through the lymphatics usually results in rapidly fatal diffuse septic peritonitis, while in thrombophlebitis there is a greater tendency to localization, unless the thrombi disintegrate and cause embolism and pyæmia.

3. PATHOLOGIC CLASSIFICATION. The pathologic conditions which character

ize the different varieties of peritonitis neccessarily must be considered in classifying this disease. The pathologic classification is based almost entirely upon the gross and microscopic appearances of the inflammatory exudation and transudation.

Every acute

a. Diffuse Septic Peritonitis. peritonitis is septic in so far that phlogistic substances reach the general circulation from the inflammatory lesion, and in that frequently the inflammation terminates in suppuration; but the term "septic peritonitis" should be limited to those cases of diffuse septic peritonitis in which, as a rule, death occurs in a few days, and before any gross pathologic conditions have had time to form. It is a disease that is almost uniformly fatal, with or without operative treatment, the patients dying from the effects of progressive sepsis. The claim of operators to have cured such cases by laparotomy must be accepted with a good deal of allowance. The microbes which produce this form of peritonitis are those which follow the lymph spaces and are rapidly diffused not only over the entire peritoneal surface, parietal and visceral, but also through the subserous lymphatic channels. The disease is observed most frequently after perforation into the free peritoneal cavity of an abscess containing septic pus; rupture, or perforation of any of the abdominal or pelvic viscera containing septic material; gunshot or stab wounds of the abdomen with visceral

injury of the gastro-intestinal canal; and occasionally as the result of infection during laparotomy. The gravest form of puerperal fever is a diffuse septic peritonitis. The subjects of this variety of peritonitis die so soon after the beginning of the disease that at the autopsy no gross tissue changes are discovered. Besides a slightly increased vascularity, nothing is found to indicate the existence of peritonitis. The septic material, formed in large quantities and of great virulence, is rapidly absorbed by the stomata of the under surface of the diaphragm discovered and described by Von Recklinghausen.

b. Suppurative Peritonitis.-Suppurative peritonitis, that is, an inflammation of the peritoneum which results in the formation of pus, is always more or less circumscribed. This form of peritonitis is the most frequent, and is generally associated with more or less fibrinoplastic exudation. The pus is either serous or seropurulent, or may reach the consistence of cream, when it usually is of a yellow color. The accumulation of pus may be so large that upon opening the abdominal cavity it may appear as though the entire peritoneal cavity and all the organs contained within are implicated, but a careful examination will almost always reveal the fact that a large part of the peritoneal cavity and many

of the organs were shut out from the inflammatory process by plastic adhesions. Suppurative peritonitis must therefore be regarded from a practical standpoint as a circumscribed inflammation. The appearance and character of the pus are often greatly modified by the admixture of an extravasation accompanying the perforative lesion which produced the peritonitis. If the pus is thin (serous) we speak of seropurulent peritonitis. It is a serous peritonitis with the formation of pus in sufficient quantity to render the serum more or less turbid. This subvariety of suppurative peritonitis is without exception in combination with fibrinous exudations, which tend to limit the extension of the infective process. Sedimentation of the solid constituents takes place, so that the fluid contains more of the solid constituents in the most dependent portion of the affected district.

c. Serous Peritonitis.-Independently of malignant and tubercular disease of the peritoneum, circumscribed hydrops of the peritoneal cavity is caused by a very mild form of peritonitis, the pus microbes present not being sufficient in quantity to produce pus. Patients usually recover rapidly from this form of peritonitis. The slight alterations of the peritoneum produced by the inflammatory process do not interfere with the transudation of serum, and resorption is affected as soon as the inflammation subsides and the normal absorptive function of the peritoneum is restored. Serous peritonitis is usually more or less complicated by fibrinous peritonitis, as fragments of fibrin are often found suspended in the blood. The serum is generally somewhat turbid, not transparent, and grayish-yellow or reddish in color. As long as the fluid is limited in quantity, it gravitates toward the most dependent parts of the abdominal cavity, in the small pelvis; when more copious, it reaches the upper portions of the peritoneal cavity and first seeks the depression on each side of the spinal column.

d. Fibrinoplastic Peritonitis.-The inflammation results in a plastic exudation with little or no effusion. The character of the exudate depends on the intensity and quality of the bacterial cause. The exudation is often so copious that it has been mistaken for malignant disease. The symptoms are marked cachexia, ascites, uncontrollable diarrhea, and apparent tumor deep in the abdomen. The exudation in the course of time contracts and results in strong bands of adhesion, which frequently flex and distort the organs to which they are attached, which has given rise to another term-peritonitis deformans.

4. BACTERIOLOGIC CLASSIFICATION.

As the essential cause of peritonitis is always the presence and action of pathogenic microbes and their toxins upon the perito

neum, and as the character of the inflammatory process is largely influenced by the kind of microbes which produce the infection, a bacteriologic classification is of the greatest scientific and practical importance. All pus microbes present in sufficient quantity and virulence in the peritoneal cavity can produce peritonitis.

a. Streptococcus Infection.-The streptococcus pyogenes is the microbe which is most frequently found in the tissues in cases of septic peritonitis. The infection spreads so rapidly over the peritoneal surface and through the subserous lymphatics that death, as a rule, occurs from septic intoxication before a sufficient length of time has elapsed for any gross pathologic lesions to form. Absence of fibrinous exudate and effusion are the most striking negative findings at operations and necropsies. Streptococcus infection is the immediate cause of the most fatal form of puerperal peritonitis. After the peritoneum has once been infected, rapid diffusion takes place, and finally the diaphragm and pleuræ are implicated in the same process, and the patient dies from the effects of progressive sepsis.

b. Staphylococcus Infection.-In peritonitis caused by staphylococcus infection the intrinsic tendency to localization of the disease is more marked; the inflammation results more often in circumscribed suppuration and limitation of the infective process by copious fibrinoplastic exudations. As a rule, the inflammation terminates in the formation of thick, cream-colored pus. Different forms of staphylococci are often seen in the same inflammatory product.

c.

Pneumococcus Infection. It is now well known that pneumonia is produced by different microbes, but the diplococcus is found in about eighty per cent of all cases. It is this microbe which occasionally is found as the bacteriologic cause of acute suppurative peritonitis. Weichselbaum has found the diplococcus of pneumonia unaccompanied by any other micro-organism in three cases. of peritonitis. In one case the peritonitis and acute pneumonia occurred simultaneously; in the other, double pleuritis followed the peritonitis, but in the last case the peritonitis was undoubtedly primary, and in the absence of any other microbes in the inflammatory product must have been caused solely by the diplococcus of pneumonia.

Bacillus Coli Commune Infection.The bacillus coli commune, a microbe that constantly infests the intestinal canal, is in a fair percentage of cases the bacteriologic cause of acute peritonitis. This microbe possesses pyogenic properties, and in intestinal paresis and perforations escapes into the peri

toneal cavity, and usually produces a pathologically mixed form of peritonitis-that is, suppurative and fibrinoplastic peritonitis.

Gonococcus Infection. In the peritoneal cavity the gonococcus produces a plastic peritonitis, and sometimes localized suppuration. Salpingoperitonitis and the more diffuse pelvic peritonitis is the most frequently caused by gonococcus infection.

f. Tubercular Infection.-The rapid diffusion of the tubercle bacillus in the peritoneal cavity, either through the circulation or by rupture of a tubercular abscess into the peritoneal cavity, or by extension from a tubercular salpingitis, occasionally gives rise to a form of acute peritonitis characterized as such in a modified way by the clinical manifestations which accompany it. According to the intensity of the infection, or the degree of susceptibility of the patient to the action of the tubercle bacillus, the disease assumes one of the following pathologic forms: (1) Tubercular ascites. (2) Fibrinoplastic peritonitis. (3) Adhesive peritonitis. Suppuration takes place only when the tubercular product becomes the seat of a secondary mixed infection with pus microbes.

5. CLINICAL CLASSIFICATION.

A diagnosis for the careful physician and conscientious surgeon must include the location, extent, causation and pathology of the disease. From the information obtained from the classification already made must be obtained the material upon which to base a clinical classification. Such a classification should serve as a guide in differentiating between the cases which demand surgical intervention and the cases which can be trusted to medical treatment.

a. Ectoperitonitis.-Abscess formation in the subperitoneal connective tissue, as seen most frequently in the pelvis in women, in the cavity of Retzius in men, and in the retroperitoneal space in both sexes, is always attended by inflammation of the under surface of the peritoneum. Such abscesses should be recognized and accurately located sufficiently early to prevent serious complications by an extraperitoneal incision and drainage; or, if the abscess is of a tubercular nature, by tapping, evacuation and iodoformization.

b. Diffuse Septic Peritonitis.-This form of peritonitis is characterized clinically by the gravity of the general symptoms from the very incipiency of the disease; pathologically, by the rapid diffusion of the infection over the entire serious surfaces, visceral and parietal; and, bacteriologically, by the presence in most of the cases of the streptococcus pyogenes in the inflamed tissues. Staphylococci, pneumococci, and the colon bacillus may also be the cause of rapidly spreading

diffuse peritonitis. This form of peritonitis usually follows penetrating wounds of the abdominal cavity, complicated by visceral injuries of the gastro-intestinal canal, contusion or laceration of any of the abdominal or pelvic organs, rupture of an abscess or ulcer into the free peritoneal cavity, or the extension of a septic lymphangitis from any of the abdominal or pelvic organs to the peritoneum. Strict aseptic precautions have succeeded in greatly reducing, but not entirely eliminating, the danger from this source in all operations requiring opening of the free peritoneal cavity. In genuine cases of diffuse septic peritonitis surgical intervention is usually powerless in preventing speedy death from toxemia. c. Perforative Peritonitis.-Perforative peritonitis is manifested by the sudden onset of the disease, by diffuse pain and tenderness, rigid abdominal walls, fever and vomiting, and by the impossibility by inspection, palpation or auscultation to ascertain intestinal

peristalsis, the latter being almost positive proof of the presence of gas in the free peritoneal cavity. According to the author's observations, meteorismus peritonei in perforative peritonitis caused by affections of the appendix is rare, while he has seldom found it absent in perforations of any other portion of the gastro-intestinal canal. According to the number and virulence of the microbes which find their way into the peritoneal cavity with the extravasation, the resulting peritonitis is either diffuse or more or less circumscribed. The colon bacillus is invariably present in the inflammatory product, but, in addition, streptococci, staphylococci, putrefactive bacilli, the typhoid baccillus, or bacillus of tuberculosis, according to the nature of the primary affection, may also be found.

Perforative peritonitis must be regarded and treated as a strictly surgical disease. The primary lesion must be exposed and treated as soon as a diagnosis can be made, and the necessary measures applied to limit the extension of the infection and to prevent death from toxemia.

d.

Circumscribed Peritonitis.-The symptoms appear suddenly, i. e., are preceded by those incident to the primary disease. The severity of the pain and the extent of the muscular rigidity and tenderness will correspond with the extent of the disease. The intensity of the general symptoms are determined more by the nature and virulence of the microbic cause than by the size of the peritoneal surface involved. The inflammatory focus may be limited to a very small space, or it may involve the greater portion of the peritoneal cavity and organs which it contains. Circumscribed suppurative peritonitis is usually the result of infection with staphylococci, bacillus coli commune, and pneumococci.

In

fibrinoplastic peritonitis surgical interference becomes necessary only when intestinal obstruction is caused by the adhesions. In circumscribed suppurative peritonitis the pus should be evacuated as soon as the disease is recognized, and, if possible, by an extraperitoneal route.

Remarks on the Medical Aspect of a System Compulsory Insurance of the Working Classes.

BY F. PARKES WEBER, M. D., M. R. C. P., LONDON.

As the subject is comparatively little known to the majority of English medical men, in order to make the medical remarks intelligible, I must first give a short account of the German National Workmen's Insurance System, and this account I shall give as nearly as possible in the words of the "Guide to the Workmen's Insurance of the German Empire,' compiled by Dr. Zacher, permanent member of the Reichs-Verischerungsamt. It will, however, be unnecessary to enter into any complicated details or figures.

The work of social reform was practically initiated by the Message of the German Emperor, William I, to the Reichstag on November 17, 1881. The message, as communicated by Prince Bismarck, was expressed in the following words:

"We consider it our Imperial duty to impress upon the Reichstag the necessity for furthering the welfare of the working people. We should review with increased satisfaction the manifold successes with which the Lord has blessed our reign, could we carry with us to the grave the consciousness of having given. our country an additional and lasting assurance of internal peace, and the conviction that we have rendered the needy that assistance to which they are justly entitled. Our efforts in this direction are certain of the approval of all the federate governments, and we confidently rely on the support of the Reichstag, without distinction of parties. In order to realize these views a bill for the insurance of workmen against industrial accidents will first of all be laid before you, after which a supplementary measure will be submitted providing for a general organization of industrial sick relief assurance. But likewise those who are disabled in consequence of old age or invalidity possess a well-founded claim to a more ample relief on the part of the state than they have hitherto enjoyed. To devise the fittest ways and means for making such provision, however difficult, is one of the highest obligations of every community based on the moral foundations of Christianity. A more intimate connection with the actual capabilities of the peo

ple, and a mode of turning these to account in corporate associations, under the patronage and with the aid of the state, will, we trust, develop a scheme to solve which the state alone would prove unequal."

Thus the workingman unfitted for work by sickness, accident, invalidity, or old age was to have a legal right to a provision sufficient to render him independent of public charity or poor law relief. This end could only be attained by a sytem of general and compulsory insurance, based on mutuality and self-administration, and the endeavors to attain this end have resulted in the system of workingmen's insurance now employed in Germany. This system consists of three component parts: (1) Insurance against sickness; (2) insurance against accidents; (3) insurance against invalidity and old age. These component parts, which supplement each other to form the insurance system, must be separately considered.

INSURANCE AGAINST SICKNESS

The insurance is intended to secure the insured sufficient relief in case of illness during at least thirteen weeks. All the insured have a legal claim to:

(a) Free medical attendance and medicines from the beginning of the illness; likewise spectacles, trusses, bandages, etc.

(b) (From the third day of any illness which incapacitates from work) a daily sick pay amounting to one-half the daily wages on which the contributions have been based; or else (in special cases) free admittance to a hospital, together with half the sick pay for the family.

(c) Burial money.

(d) In case of women, sick relief during four weeks following confinement.

The insurance against sickness, contrary to that against accidents, is restricted to local organizations, because cases of less importance are continually occurring in which relief to be efficacious must be prompt. The law has therefore authorized the formation of various associations for obligatory insurance against sickness. By the associations being local and self-administrative the management of their funds is more easily controlled, and simulation on the part of the insured is more difficult. The contributions of the different classes of workmen vary from 1 to 3 per cent. of their average daily wages. The law binds the employers themselves, when depositing the contributions of their workmen, to pay a sum equal to onehalf the contributions of the employed, so that two-thirds of the whole are furnished by the workmen and one-third by their employers.

INSURANCE AGAINST ACCIDENTS.

The liability law of June 7, 1871, had not the desired effect, partly because the burden of proof was laid on the poor workman seeking