J. DISEASES OF THE PERITONEUM
of the peritoneum.
Etiology.--It may be primary
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.
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
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.
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.
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
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.
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.