Discussion on Pneumococcal Peritonitis

Abstract

said he felt rather surprised when Dr. Cameron laid such stress on the mistakes in diagnosis which might be made between pneumococcal peritonitis and typhoid fever or tuberculous peritonitis, because he had never himself seen one of these. The cases he, as a surgeon, saw which caused confusion were those in which the question was whether the disease was acute appendicitis or not. All the cases which came under his observation had been exceedingly acute. The onset had been very sudden; the patients had been taken into hospital usually within forty-eight hours of the onset, sometimes within twenty-four hours of it, and the peritonitis had been so acute and so little distinguishable from that due to a gangrenous appendix, that they had been operated upon at once. In only one of the cases of that nature that he had seen had there been a recovery. He was sorry he could not be as optimistic as Mr. Waugh: in his experience the mortality from the condition had been very heavy in the early and fulminating cases. Of these he had seen only three in about the last six years. Shortly before the war a paper was published in the St. Bartholomew's Hospital Reports, vol. xlviii, p. 137 et seq., by Moreton and Noon, in which it was evident that the authors had difficulty in collecting six cases in seven years in that hospital. Therefore the figures for the north side of the river seemed to be fairly low.An important point in the diagnosis at operation was the absence of smell in the effused fluid in the case of pneumococcal peritonitis. When there was no bad odour in the abdominal fluid, it showed that it was neither appendicular nor from the bowel, and if there was sufficient history to distinguish it from tuberculosis it made the diagnosis clearer. One patient of his on whom laparotomy was done recovered. This particular case was diagnosed as appendicitis, and the lack of odour in the pus made him think it was pneumococcal. Pneumococcus was isolated and Type I pneumococcal serum was used intraperitoneally, and the child recovered. He had since heard of another, a fulminating case in which the patient was given the same serum, and also recovered.With regard to residual abscess in the peritoneum, in his case in which the patient recovered, five weeks after operation, when the temperature was coming down slowly, a painless abscess developed in one forearm, two days later one in the upper arm, and four days Ilter one on the buttock. These abscesses contained pneumococcus in pure culture.Directly the abscesses appeared there was an improvement in the child's condition and complete recovery followed.He asked whether any members had had experience of treatment of this disease by serum and vaccines, or had had experience of distant metastatic abscesses.Dr. E. BELLINGHAM SMITH said he had an abstract of the notes of eight cases, seven of which had occurred at a children's hospital since 1920, and one at the Great Northern Hospital, which had been operated upon four years ago.He agreed with what Dr. Cameron said about these cases, and dis...