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Impaired Health Its Cause And Cure by J. H Tilden, M.D.

J. DISEASES OF THE PERITONEUM
I. PERITONITIS

   Definition.--Inflammation of the peritoneum.

   Etiology.--It may be primary or secondary.

   Primary Peritonitis.-This is of very rare occurrence. When it does occur, it probably develops from cold or exposure, or from a rheumatic state of the body. Not having seen a case of the kind, I can do no more than mention the fact that primary inflammation is recognized by most authorities. I have seen a great many cases of peritonitis, but always of secondary origin.

   Secondary Peritonitis.--This inflammation is an extension of other inflammations. Diseases of any of the viscera--of the chest, abdominal cavity, and pelvis--may end in peritonitis. Diseases of the liver, with abscess or simple inflammation, may extend to the peritoneum. Gallbladder diseases, malignant diseases of any part of the abdominal cavity, or of the thoracic or pelvic region, may extend to the peritoneum. Ulceration of the stomach, ulceration of the bowels, colitis, muco-colitis, appendicitis, typhlitis, ovarian and uterine inflammations, septic inflammation of the uterus following childbirth or abortion, may extend to the peritoneum. External wounds of the abdomen may by ulceration perforate the peritoneum. Abscesses in the cecal region, or the region of the appendix, will sometimes break into the peritoneum. This means fatal peritonitis, unless the case is operated upon at once, and the cavity thoroughly cleansed and drained. Perforating ulcer of the stomach and duodenum will cause fatal peritonitis. There is no hope for such cases, unless the peritoneum is opened, and thoroughly cleansed and drained.

   Symptoms.--Inflammation of the peritoneum is ushered in by a chill or chilly feeling. In severe cases the chill amounts to a rigor, with intense pain in the abdomen and aching in the back; in fact, aching all over the body.

   In low forms of typhoid fever, where the perforation has occurred after the system has become thoroughly toxemic and the brain dulled by the toxins, the symptoms may develop so insidiously that a fatal state will be evolved before the dangerous condition of the patient will be suspected. However, the watchful physician will observe a swelling of the abdomen, which is a distention of the peritoneal cavity. In other words, tympanitis must be distinguished from gas in the bowels. Both of these distend the abdomen, but there is a vast difference in the two cases. Where tympanitis exists, it means infection of the peritoneum, and, if it is the result of perforation, death will result very soon--within a few hours. In septicemia, following childbirth or abortion, intense pain in the abdomen, quick pulse, flushed face, preceded by a rigor, mean a fatal case, unless it is quickly comprehended and the right treatment used immediately.

   Treatment.--Inasmuch as peritonitis is secondary to a primary disease, it is necessary to know what the primary disease is. The treatment must be directed to the correction of that disease. Of course, in cases that are rapidly fatal, like perforating ulcer, it is too late to do anything for the primary disease, and all the remedies that can be used must be directed to correcting the secondary disease, which is, peritonitis, As suggested before, if there has been a perforation, the peritoneum must be opened, cleansed, and drained.

 

II. CHRONIC PERITONITIS

   This is a slight affection at the start. There may be a slight infection of the peritoneum from an extension of the disease in the pelvis. There may be a slight infection following an operation which opens the peritoneum. This disease often ends in adhesions--by adhesive inflammation. In that case the treatment must be for the removal of the adhesions. Following the removal of ovarian and fibroid tumors, normal ovariotomy, and operations for appendicitis, we hear of a great deal of trouble caused by adhesions. In many cases there are no adhesions, the pain and discomfort complained of by patients being due to intestinal indigestion and a distention from gas; but in these days we are having a great many patients sent to the hospital for secondary operations, for the purpose of breaking up old adhesions, etc. Every case must be a law unto itself, and whatever is necessary should be done. I have not met with so many adhesions as one would suppose in an active practice in a country where this derangement is heard of often, following the numerous operations to which people are subjected.

 

III. ASCITES

   Definition.--Accumulation of serous fluid in the peritoneal cavity.

   Etiology.--This affection is secondary to inflammations, or slight extension of inflammations from other organs. It may be due to cancer extending to the peritoneum, tuberculosis of the peritoneum, or portal obstruction or cancer extending from the liver to the peritoneum. Pyemia may be a cause of this affection; also tumors in the abdomen, large fibroids or ovarian tumors, or hydatid disease of the liver.

   Ascites becomes a part of the general dropsy brought on from heart enervation. Lung affections, such as emphysema or sclerosis of the lungs, cause dropsy. Ascites occurs also in dropsy brought on from Bright's disease of the kidneys.

   Symptoms.--Gradual enlargement of the abdomen, sometimes starting with puffiness of the feet and ankles. The history of the case will throw some light upon it and aid in differentiating between ovarian tumor and ascites.

   In percussing over an ovarian tumor, the resonant sound peculiar to percussing over the intestine is entirely eliminated. The sound is dull over the lower abdomen, and when the percussing extends above the umbilicus, if there begins to be a resonant sound it will be known that that is the upper part of the tumor. Then, going laterally on each side down into the small of the back, there will be more resonance on both sides, showing that the tumor rests upon the intestine. Sometimes a loop of intestine will rise between the tumor and the wall of the abdomen. In that event it requires a little more skill in diagnosing to determine whether it is a case of ovarian cyst or ascites. The experienced diagnostician, however, will not have much trouble; for, by introducing the finger into the vagina and passing up in front of the neck of the womb with one hand, and then having the other hand placed on the abdomen, the sensations of the two palpating hands or fingers will be carried to each other, showing a continuation of a fluid medium; whereas, if the hand can be placed upon the top of the swelling, above the umbilicus, and pressed down, and, with the finger in the vagina and to the anterior of the neck of the womb, nothing can be felt between--if the percussion wave does not extend to the finger in the vagina--then it will be known that the disease is ascites.

   Treatment.--For ascites, where the symptom is very distressing, a little palliation may be secured by tapping and drawing off the water; but it will fill up very soon again, and the patient will have to be tapped again and again, until he is worn out and dies from exhaustion. If the affection has not evolved into such a desperate type, fasting will give relief; and, in fact, this is the only hope of carrying a patient back to a reasonable state of health. If the ascites is due to a cancerous extension, there is no hope. If the disease is due to a pyemic infection from, say, liver abscess, if the abscess can be drained there is hope of a betterment, and possibly a cure. In acute peritonitis from extension of pelvic inflammation, the pelvic disease must be corrected as quickly as possible; and if the peritonitis is extensive, there is a possible hope in opening the peritoneum and washing it out, and then draining. These cases are never very promising.

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