I think that interpretation is much more reasonable than to say that he had a second flare-up of ulcerative colitis. It would be unusual for a man to be as sick as this, with his temperature going as high as 104, without more pain in his abdomen if he had a severe enough ulcerative colitis to give this picture. Furthermore, the possibility of colitis could not be entertained for long because we have no further information about the stools, tenderness along the colon, or anything of that sort, which would help to make such a diagnosis. So I would be inclined to throw out the possibility of this man having ulcerative colitis.
I suppose the one thing that is really striking and that we must either take seriously or throw out is the question of typhoid fever. He had a temperature of 104 F., and a pulse of 75, a white count of 7,000, and a positive Widal of 1:320. A positive Widal this early in typhoid is very unusual. On the other hand this man had been vaccinated. Did the Widal become positive nonspecifically because the individual was suffering from a severe infection of some sort? I personally would be inclined to interpret it that way.
If he has typhoid we have to presuppose that he has ruptured his small intestine, but again if this is typhoid it is far too early in the course of the disease for such a complication. There is absolutely nothing on physical examination that would point to typhoid. There are no rose spots, no enlargement of the spleen, and no lead whatsoever that would enable one to make that diagnosis. People with septicemia have chills and fever, and at certain times they have relatively slow pulse and low white count, whereas at some subsequent time a high pulse and an increased white count will develop. Therefore, I would throw out the possibility of typhoid fever. As I said before, he evidently died because of something very radically wrong with his abdominal cavity.
One of the first things we should think of is whether we are dealing with an individual with peritonitis subsequent to rupture of some viscus. But there is nothing here to enable me to say that he had a ruptured viscus. His last illness started without any abdominal pain or symptoms. For three days the only symptom he had, with reference to his gastrointestinal tract, was diarrhoea, which may have been due to frequent catharsis. They evidently suspected a ruptured viscus because several flat plates of the abdomen were taken. On no occasion did they find anything suggesting air under the diaphragm.
The question of whether he may or may not have had ulcer four years ago is thrown in for good measure, but again there is nothing in the history to allow me to believe that he has a ruptured ulcer and subsequent peritonitis.
The other possibility is whether we might be dealing with a man with multiple diverticula and associated diverticulitis with rupture and peritonitis or abscess formation. There is nothing in the physical examination which would allow one to state that that had been the case.
I would like to know if he had a septic throat. I think it is unusual without an antecedent sore throat, but his illness evidently started off with an acute infection and probably a blood stream invasion almost from the start. If he had had a septic sore throat, that could be the source of entry for such an infection. Of all the laboratory work, the only blood culture on which I think we can really place any reliance is the one which contained hemolytic streptococcus. It is unusual to get hemolytic streptococcus as a contamination, whereas the other two organisms could conceivably be contamination. So we can say that we have some laboratory evidence which enables us to state that we are dealing with an individual who does have a septicemia.
I would be inclined to take one long guess on this man and say that he probably had a peritonitis secondary to the septicemia, and he died of a hemolytic streptococcus peritonitis. If you want to call it idiopathic in origin, all well and good. I could go on and make a complete differential diagnosis, but I do not think I would get any farther than making this one guess. I cannot entertain the question of typhoid and the various other things very seriously. If he did not die of streptococcus peritonitis, I have no idea what he had.
Dr. B.: While you are guessing, I wonder why you lost interest in the appendix in the middle of your discussion. The point is, we have been tricked a great many times by the appendix, and this story could be perfectly well accounted for by an atypical appendix right from the start.
Dr. A.: The thing that intrigued me when I first went over the history was the fact that we might be dealing with a lesion that started five months ago as an attack of appendicitis.
It is possible that he had a ruptured appendix at that time and had been carrying an appendiceal abscess since then. You see an occasional individual walking about with an appendiceal abscess for some time, with very little in the way of symptoms; but such individuals are very rare. The other thing that intrigued me was whether he could have a pylephlebitis secondary to appendicitis; but he goes five months without chills, fever or jaundice, and no tenderness of the liver–never anything to suggest it. When we come to the final illness, it is hard for me to believe that the first three days represent anything more than an acute infection.
There is nothing in the history except diarrhoea to suggest anything in the abdomen, and for that diarrhoea we have a reasonable explanation, that he took a cathartic on these three days. Not until the fourth day were the symptoms referable to the abdomen, and then they do not sound much like appendicitis. I suppose there is a possibility that I may have missed a ruptured appendix with widespread peritonitis. He came in with a temperature of 102, a pulse of 75 and a white count of 7,000. I think that set-up with an acute appendix would be unusual, even if it had ruptured. I think that if it had ruptured he would have obvious signs of peritonitis. It was not until the fourth or fifth day that he presented evidence that made me feel certain of peritonitis. I think a pulse of 75 and a temperature of 102 in appendicitis with or without rupture is an unusual set-up.
Dr. B.: It is an unusual set-up under any circumstances.
Dr. A.: No one knows better than I.
Dr. C.: Idiopathic peritonitis is rare at that age.
Dr. A.: I appreciate that it occurs usually either in childhood or adolescence. I wish we knew whether he had a septic sore throat That is important, that plus the positive blood culture.
Dr. D.: I do not believe that it is not an idiopathic peritonitis. I would have asked the same question Dr. B. did, why you abandoned appendicitis and diverticulitis so readily. I also wonder if one should not consider the possibility, at least, of a local and general sepsis due primarily to cancer some where in the colon.
Dr. A.: There is very little to suggest anything in the colon. My experience is that colitis cannot go on without any evidence.
Why do you say that he died of appendicitis with rupture and so forth? The way I interpret the history is that he has gone three days without any evidence of anything in his abdomen. I would like to have the reaction of one of the surgeons on that. Does his illness during the first three days sound like appendicitis to you, Dr. E.?.
Dr. E.: I would say not, on the evidence we have here.
Dr. A.: I should think that the same sort of reasoning would be correct if you are going to presuppose diverticulitis with rupture. I think that the abdominal examination on the fourth hospital day would be different from what it is. I grant you that I am making a long guess, but I have thought a great deal about this case, and I could not reason it out any other way. I do not believe that he had a ruptured viscus.
Dr. F.: The rectal examination rules out long-continued appendicitis. It is true that pelvic abscess and appendicitis could explain the story, but here we have a rectal examination that rules them out.
A Physician: Four members of the family have had typhoid fever. He perhaps was a typhoid carrier and was ill several days before he came down with an acute chill.
Dr. A.: You mean that he was a carrier for twelve years and then came down with typhoid? I could not make a diagnosis of typhoid because of the rapidity with which this mans illness goes from the time he became ill. In that case we would have to pre-suppose a rupture of a Peyers patch on about the fourth day of the illness.
Dr. G.: I think that he was ill before he had the chill. He was ill when he took the laxative.
Dr. A.: The only story we have is that he was run-down and not up to par. If he has had for five months the pre-symptoms of typhoid, it is unusual. I prefer to date his illness from three days before he entered. If he has typhoid he has ruptured on the fourth day, and that is too early; besides, there is no good evidence.
Dr. G.: I do not believe that the positive Widal of 1:320 would come from vaccination twelve years before.
Seattle.
Chairman, Bureau of Surgery