Peritonitis

“ Perforation is very rare in cases of follicular ulceration, and is by no means frequent in the diphtheritic process, but it is the most frequent cause of peritonitis in chronic dysentery. It may occur in any part of the colon, but does occur most frequently in the cæcum. The resulting peritonitis is fatal as a rule, but the danger is obviated sometimes, as in typhoid fever, by agglutination of the gut to a contiguous structure or viscus. Perforation usually occurs late in the disease, but it may occur very early. ”

“ Kalantarians says, in eight examinations of the solar and hypogastric plexus in persons who had died of acute peritonitis changes which he regards as inflammatory had occurred, with subsequent opaque swelling of the nerve-cells, ultimate fatty degeneration, brown pigmentation, and atrophy. In chronic peritonitis the cells are often converted into amorphous pigment matter, with increase and sclerosis of the ganglionic connective tissue. Still, it is worthy of notice that these changes do not express themselves in symptoms in those that recover. ”

“ Now, it seems to me that a great deal depends on the kind of infection--or, rather, the kind of organism infecting--and often the difference between a localized abscess and a general peritonitis is really the difference between a colon and a streptococcus infection. Again, should a general peritonitis develop, I have noticed from a number of cases in the wards that the prognosis practically depends on the organism, although we all know that a general peritonitis is a mighty grave condition, no matter what it is due to. ”

“ Benign tumors of the abdomen are not frequently the cause of general peritonitis, and when they are, the grade of the disease is acute rather than chronic. They very often provoke local inflammation and become adherent to the neighboring structures. The same is true of malignant growths in the abdominal cavity, except that the adhesions are earlier formed and more likely to occur. Localized cancer, of whatever variety, is not very prone to produce general peritonitis, even though there be multiple developments of it. ”

“ So is peritonitis often the result of disease previously latent, but brought on by exposure to cold, or some such agency. Some men say that such cases as those of doubtful sanity should not be taken up by us—that ordinary men are quite as well fitted for finding out the truth as we are, with all our training. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ Constipation is absolute in uncomplicated peritonitis of ordinary severity, and I believe is caused by a temporary paralysis of the muscular layer of the intestine. It has already been stated that the blood-supply of the peritoneum is through vessels whose capillaries are shared by that membrane and the tissues which it covers. Inflammatory action in the peritoneum of average severity would naturally extend to this muscular layer and render it inactive. When the inflammation abates it recovers its contractile power. ”

“ These symptoms progressively increase in severity, and reach their maximum intensity in from three to five days. The pulse then becomes small, compressible, and irregular, the extremities cold, the face hippocratic, and death takes place in a state of collapse. The fatal termination is preceded by the symptoms of acute peritonitis in the cases which are complicated by an extension of inflammation or the rupture of an abscess into the peritoneal cavity. ”

“ These cases of injury to the bladder may die suddenly and speedily from shock or from peritonitis in three to seven days, or not until fifteen days or so. In punctured and incised wounds the urine escapes more slowly, peritonitis develops less early, and death is longer delayed. Hemorrhage in injury to the bladder is not usually serious; the blood is found partly in the bladder, partly in the pelvis, where the fluid extravasated by peritonitis is also found. The victim of a wound or rupture of the bladder may often walk about for some time after the injury. ”

“ The closure of the tubes is not the only result that may follow the course of this disease. The infection may extend into the peritoneal cavity causing peritonitis, which so often results in the59 untimely death of the woman. Here let me say that not all cases of peritonitis or of inflammation of the womb, tubes or ovaries are due to this infection. There are other infections, other germs, that may produce similar results. These germs may reach the organs in various ways. Sometimes the woman herself is to blame and sometimes we can blame no one. ”

“ Small-sized sharp bodies cause lesions of trifling extent, which in most cases are only indicated by retardation of movement of the gastric compartments, between which and the diaphragm, and between the diaphragm and the posterior portions of the lung, various adhesions are set up. In such cases the peripheral inflammation ends by producing a fibrous sleeve, which prevents the pleural cavity becoming infected. Other cases show patches of adhesive peritonitis or signs of generalised peritonitis, the real cause of which often evades discovery during life. ”

“ After the appearance of these symptoms, a more or less firmly adherent but limited perityphlitic abscess, and a less intense although well developed peritonitis in this region, were assumed; the latter, notwithstanding the painful meteorism, was not necessarily diffuse in the strict sense of the term; the omentum often protects the upper abdominal cavity from infection, as was proven in this case at the autopsy. ”

“ Proctitis may exist with follicular ulcers; ulcers form in the cæcum, sigmoid flexure, and in the bends of the colon; perforations and peritonitis rarely occur. Chronic peritonitis has resulted from the stretching of the bowel from retained and hardened feces; adhesions may form which ultimately cause death by obstructing the canal. The walls of the intestines are in long-standing cases much thinned. There are many reasons to believe that fatty degeneration of the smooth muscular fibre takes place, in consequence of which it loses its contractile power and atrophies. ”

“ 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. ”

“ Sometimes there is the evacuation of pus by the anus or of the investing membrane of the abscess, and this may be expected to herald recovery. In case of infective peritonitis there are the usual symptoms of stiff movement, the bringing of the feet together under the belly, abdominal tenderness, trembling, hyperthermia, cold ears and limbs, cold perspirations, great dullness and prostration, small, weak or imperceptible pulse, hurried breathing and gradual sinking. ”

“ The symptoms of acute peritonitis are all toned down, but do not all disappear. Vomiting occurs occasionally; tenderness is diminished, but is quite perceptible; meteorism diminishes, but fluctuates greatly; appetite is poor or variable; constipation alternates with diarrhoea or is followed by dysentery; now there is a febrile heat, and then the temperature is normal—this fever is most likely to come in the evening; the pulse is frequent and varying; ultimately extreme emaciation and anæmia. ”

“ 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. ”

“ In lead colic there is no fever, tympanites, nor diarrhoea. In rheumatism of the abdominal walls the pain is superficial and sharp, not griping, and is increased by movements of the trunk. The digestive system is in no way disordered. From peritonitis intestinal catarrh is distinguished by a less degree of illness and by its usually favorable result, by diarrhoea, a greater freedom in movement, and by a less degree of suffering on palpating the abdomen. Tympanites, constipation, great tenderness on pressure over the abdomen, and a small, quick pulse, point to peritonitis. ”

“ Unfortunately, in exceptional cases it may also happen that the number of embryos in the abdominal cavity is so great as to produce lesions of acute hepatitis, acute peritonitis, and sometimes pleurisy. These grave forms are more common in young pigs and lambs.
The animals appear dull, feeble, exhausted and without appetite, but exhibit marked thirst, lose flesh and become anæmic in a few days. Soon afterwards they show symptoms of acute peritonitis, with exudation of fluid, and death may follow in a week or two. ”

“ Severer attacks occasionally occur with violent colic and inflammatory symptoms, the tumor formed by the misplaced organ becoming exceedingly sensitive to pressure. These have been attributed to some [p. 24] incarceration, but there is no evidence that this accident occurs, and it has not been found after death. They are probably due to a localized peritonitis of the investment of the kidney, or perhaps to simple neuralgia. Icterus and hepatitis, consequent upon a circumscribed peritonitis set up by the pressure of the movable kidney upon the liver, have been observed. ”

“ From advanced or chronic peritonitis it is distinguished by the history or evidence of diseased liver, heart, or kidney, the absence of hyperthermia or abdominal tenderness, and the absence in the ascitic fluid, extracted with a hypodermic needle, of blood globules, or leucocytes in numbers, of false membranes, of excess of salts, or of a tendency to coagulate firmly. ”

“ At any moment the foreign body may lodge, become impacted in the canal, and all the grave symptoms of enteritis and general peritonitis present themselves. Symptoms of inflammation may appear, and after a longer or shorter time suddenly disappear, as if the foreign body had glided over some point of obstruction and again begun its descent through the tube. ”

“ If the impaction is not overcome, death by collapse or from peritonitis follows. Post-mortem examination shows enormous fecal accumulation, peritonitis as a consequence of the obstruction, perforating ulcer in some part of the large bowel, more often the sigmoid flexure, or, in some cases, absolute rupture of the cæcum itself, and escape of its contents into the peritoneal cavity. ”

“ In the so-called peritonitis lymphatica the inflammatory symptoms are at the outset lacking. The abdominal cavity is found filled with a thin, stinking, greenish or brownish fluid composed of serum and micrococci. The intestines are lax and oedematous, and the muscular structures are paralyzed, with resulting tympanitic distension. The peritoneal covering of the intestines is devoid of lustre, and covered with injected patches, or is stained of a dark-brown color. Death often ensues before the occurrence of exudation. ”

“ Peritonitis.—Prognosis grave, but some cases have been reported as cured under adjustment. These are probably localized rather than diffuse inflammations, usually pelvic.
Pertussis, or Whooping-Cough.—Tends to run its course despite adjustments, though some aborted cases are reported. All cases mild under adjustment, with small liability of complications. A nervous cough is likely to persist for months after the infection has passed. Adjustments seem seldom to prevent contagion. ”

“ The point of rupture, however, then closed, and partly perhaps to the action of fresh infectious and toxic material, perhaps only to the perforation of the appendix, may be ascribed the exacerbation of the peritonitis, that is, a renewed attack which caused the death of the patient. ”

“ Rectocele and cystocele and rectal and vesical catarrh often cause painful and severe functional disturbances of the rectum and bladder. In descent of the third degree excoriations of the exposed vagina and cervix sometimes cause extreme suffering. The course is ordinarily chronic, but attacks of acute vaginitis and pelvic peritonitis are not uncommon. The peritonitis sometimes effects a spontaneous cure by peritoneal adhesions which fasten the uterus in an elevated position and hold it permanently. The symptoms of descent may be so severe as to necessitate absolute rest in bed. ”