Perizzites

“ The periosteum becomes inflamed; a widespread suppurative periostitis is the result; necrosis of the bone from insufficient nutrition follows, while mechanical pressure on the pus aids in its absorption. The medulla frequently takes on suppurative inflammation, and here the surgeon fails to receive prompt warning of danger; slowly the suppuration progresses, without pain or other symptoms unless the disease has extended to the other tissues; the medullary cavity at the fractured end of the bone may be completely or partially occluded by a new osseous formation ”

“ Peritonitis is an inflammation of the serous membrane lining the cavity of and covering the viscera contained within the abdomen. It is very rare to see a case of primary peritonitis. It is, however, somewhat common as a secondary disease from extension of the inflammatory action involving organs covered by the peritoneum. Peritonitis is often caused by injuries, as punctured wounds of the abdomen, severe blows or kicks, or, as is still more common, following the operation of castration. It follows strangulated hernia, invagination, or rupture of the stomach, intestines, liver, or womb. ”

“ The bladder, on account of its close relationship to the cervix, is always involved in the last stages. The disease may extend to the vesical mucous membrane, and symptoms of cystitis will appear. Sometimes the vesico-vaginal septum is destroyed and a urinary fistula results. Extension to the rectum is not so common. As the disease extends upward the peritoneum may be perforated, though this is an unusual accident. In most cases peritoneal involvement is preceded by local inflammation and by adhesions which prevent direct penetration of the peritoneal cavity. ”

“ As regards the treatment of acute peritonitis, the first thing that the surgeon has to do is to assure himself that the disease is not due to some cause which itself should be dealt with, to a septic disease of appendix or Fallopian tube, for instance, or to a toxic condition of the uterus, the result, perhaps, of a criminal or innocent abortion, or to a perforated ulcer of stomach or intestine. ”

“ The same train of symptoms supervene when the contents of the intestinal canal have been effused into the peritoneal cavity, through an opening in the stomach or bowel, caused either by slow destruction of the coats, the peritoneum giving way last, or by a rapid ulceration or sloughing process, as in hernia. The patient may live in agony for a day or two, but death generally takes place much within twenty-four hours. The same may be said of the rupture of the bladder, from external violence, with effusion of urine into the peritoneal sac. ”

“ When the peritoneum is eaten through it is called perforation, for it means that there is an opening into the peritoneal cavity, and, unless the cavity is cut into, cleaned and properly drained death will take place in a very short time. I say death is inevitable without surgical treatment. In this I appear to be more radical than the most radical, for the best authors have much to say about perforation, diffuse peritonitis, and of patients who live after perforation, as though it were a common occurrence ”

“ In these instances the pus shows a marked tendency to spread, strips the periosteum from the bone, perforates the outer layer of the membrane, and finally infiltrates the surrounding tissues.
This forms a near approach to what is known in human surgery as an infective periostitis, and in our subjects is nearly always met with in cases of severe prick. Its rapidly spreading character makes it always a dangerous condition, and a punctured foot exuding a discharge of this nature should always be regarded as serious. ”

“ As regards the movements of the large intestine, they resemble those of the small, although they are much less frequent. The forward movement is slow, thus permitting of the solidification of the contents by the removal of the Water. In the first part of the large intestine anti-peristaltic movements are frequent, the regular peristaltic downward movements only becoming prominent when the descending colon is reached to carry contents to the rectum. The anti-peristalsis serves a useful purpose in giving time for the absorption of the fluid in the formation of faeces. ”

“ When many deep-seated vessels send a copious defluxion to the eyes, we have recourse to the operation called periscyphismus. These cases are attended with such symptoms as these: in the first place you will find the patient’s eyes atrophied and small, weak of sight, the canthi corroded, and the eyelids ulcerated, the hairs falling off, with a discharge of very thin, acrid, and hot tears; there is a deep-seated pain in the head of an acute and violent character, and there is frequent sneezing. ”

“ Because when a drug, given hypodermatically, purges, it is not proof that the drug acts as a cathartic in the circulation, and that it does not act locally, for it may be inactive till it is excreted by the intestinal mucous membrane, and then act locally.
At present I will speak of peristalsis only. Perhaps as good a way as any to proceed, though unsatisfactory, is, first, to exclude the brain, and then, second, the abdominal ganglia, and then, third, experiment on the excised living intestine. ”

“ In contraction the powerful, writhing peristalsis involves the small intestine above the impediment, and in stricture the large bowel above the obstruction. In both stricture and contraction inflammation of the bowel and peritoneum may supervene. In contraction, when inflammation sets in or when enteritis and peritonitis are absent and the attack of constipation is insurmountable, I have noticed that the symptoms are more urgent and rapid in their course, and danger of death from collapse greater, than when these conditions exist in stricture. ”

“ Prominent among these are injuries which have been inflicted upon the intestines, compression of the colon, or rectum, perforation of the stomach or bowels, either by violence or some pre-existing disease, thus allowing the discharge of blood, urine, bile, or fecal matter into the abdominal cavity; also abortion, over-exertion, and exposure to wet or cold. As acute peritonitis is always a grave disease, involving more or less danger to life, it is the wisest course to employ a physician and trust the case to his management. ”

“ In the periosteum we may take it roughly that inflammation runs a course similar to that occurring in soft tissues elsewhere. There is but one exception, and that, as we shall mention shortly, is connected with its deeper layer.
As we know, the periosteum consists of two layers, an outer fibrous and an inner yellow elastic, and is extremely vascular. Numerous bloodvessels ramify in it, and, with their attendant nerves, break up to enter the numberless canals of the Haversian system. This extreme vascularity, of course, favours abundant exudation. ”

“ In the grave forms, where inflammation and infection extend to the peri-vesical tissues and the peritoneum, death by peritonitis is the rule.
On post-mortem examination, the mucous membrane is seen to be of a greyish colour, and sloughing or gangrenous over surfaces of varying size, whilst the surroundings are infiltrated, blackish and greatly thickened. The whole of the connective tissue layer which supports the peritoneum near the base of the bladder, and also the adipose tissue around the bladder, are markedly inflamed. ”

“ The flat bones often show well-marked periostitis, but the great thickening sometimes seen in certain of the bones of the head appears to be the result of a special osteo-periostitis. It is quite certain that the disease is due to something more than a mere want of mineral constituents in the bone, and poverty in this respect certainly does not explain the hypertrophic changes. The nutrition of the bones as a whole is disturbed, resulting in alterations both in the ossein and in the mineral salts, the whole process being accompanied by symptoms of osteo-periostitis. ”

“ For the same reason a sedentary mode of life loses force as an argument in its production. Perhaps the most efficient cause of the condition is a local [p. 817] paresis of the muscular tissue of the cæcum produced by the irritation of intestinal catarrh, of disease virus, of a fecal concretion or a foreign body—an irritation which may induce first a spasmodic action, and subsequently, as a result, a partial paralysis or a paresis. The same condition may be brought about more directly by the presence of a centre of irritation—viz. by reflex inhibition of innervation. ”

“ Instead of passing through the abdominal wall, the foreign substance may escape into the bladder or vagina, or from the small intestine into the colon or rectum. Dangerous peritonitis may follow the simple presence of the foreign body in the alimentary canal from the obstruction it produces when no attempt at discharge by ulceration has been made. If the size and shape of the body permit its passage into the small intestine, it makes its way very slowly along this tube, giving rise to occasional attacks of colicky pains and symptoms of partial impermeability of the bowel. ”

“ Without the possibility of seeing the relations of a movement to the ends of the intestine, it cannot be stated absolutely whether the movement is peristaltic or antiperistaltic. Such relations can be seen on the fluorescent screen only near the stomach and near the ileocæcal valve. The evidence that advancing peristalsis is the normal movement is so overwhelming that I have assumed that when food is moving in loops not visibly related to fixed points it is moving forward. ”

“ Differences in the rate of growth between the length of the body wall and the length of the mesocolon may play an important part in the production of peritoneal fossæ, small pouches which in some regions of the abdomen may assume considerable proportions. Such fossæ are found around the duodeno-jejuneal angle, the cæcum and appendix, and the sigmoid flexure. They will be considered more in detail with these respective regions, especially in reference to their relation to retro-peritoneal hernia. ”

“ The old idea that in peristaltic action lay the great danger of increase of the hemorrhage and perforation of the bowels, is giving way to the more rational view that gaseous distention and septic absorption, are what bring about fatal results from these complications, and that the moderate peristalsis of the intestinal walls lessens these dangers by closing the gaping ends of the injured vessels, and expelling the septic matter and foul gases. ”

“ If time be given these faithful guards to mass themselves in the peritoneal lymph channels, they will prevent the extension of the peritonitis from this point. The surgeon, having evacuated the pus, removed the appendix, and inserted the drainage apparatus, is tempted, because of its bad smell, to wash out the wound. Such a measure would not only give the patient detrimental annoyance, but would inflict a new traumatism upon the tissues. “This traumatism calls out an unnecessary number of leucocytes, and an unnecessary degree of reactive inflammation ensues. ”

“ Peritonitis occurs in phthisis as an acute and as a chronic affection. When acute, it is caused by intestinal perforation incident to ulcerations; this is a rare accident. It is to be inferred whenever the symptoms denote rapidly-developed acute peritoneal inflammation. The peritoneal sac contains intestinal gas. Perforation is excluded if percussion shows dulness or flatness over the site of the liver. The normal hepatic dulness or flatness on percussion is always abolished if the peritoneal cavity contains gas. ”

“ This gives rise, as a rule, to sudden and intense abdominal pain, together with vomiting and signs of collapse, viz., a rapid flickering pulse, cold clammy skin, and the marked fall of tempera ture. Symptoms of peritonitis (see PERITONITIS) quickly supervene and add to the patient's distress. Death usually takes place within 24 hours. Occasionally peritonitis, apart from perforation, is the cause of death. (4) Occasionally, but rarely, hyperpyrexia (excessive fever) . (5) Complications, such as pulmonary or cerebral inflamma tion, bedsores, &c. ”

“ The contents of the stomach, instead of being diffused throughout the peritoneal cavity, may be confined by a rapidly-developed circumscribed peritonitis to a space near the stomach, or perforation may occur into a space previously shut off from the general peritoneal sac by adhesions. ”

“ Exudation, which was demonstrable both by palpation and percussion. It was the natural consequence of inflammation of the peritoneum, and was both of diagnostic value as indicating general peritonitis and of special value in that, more definitely than the pain, it pointed to the original seat of the affection, which, according to present indications, could only have been an internal incarceration following right-sided inguinal hernia, or femoral hernia, or appendicitis. ”

“ In a majority of acute cases, though, which show no signs of improvement by the fifth to seventh day, it is safe to suspect periostitis, particularly if the coronets are very hot, the pulse full and hard, and the lameness acute. In the fortunately rare cases in which the bone is affected with inflammation and suppuration the agony of the patient is intense; he occupies the recumbent position almost continually, never standing for more than a few minutes at a time; suffers from the most careful handling of the affected feet ”

“ Yet a knowledge of the fact is often of the first importance, in order to obtain a favorable result from the treatment to be instituted. It is, however, quite evident that in a majority of instances the bony growths which so frequently appear on the surface of their structure, to which the general term of exostosis is applied, have had their origin in an inflammation of the periosteum, or enveloping membrane, and known as periostitis. ”