XXI. Diseases of the Peritoneum.
Definition:—An inflammation of the serous membrane which lines the walls of the abdomen, and is reflected over the viscera. It may involve the entire membrane—general peritonitis—or it may be strictly local in character—local or circumscribed peritonitis.
Etiology:—At one time it was supposed that this disease occurred as the direct result of cold or from external or traumatic causes, and was thus idiopathic in character. The belief is now universal that it is due to infection in every case, although the vitality of the membrane and its susceptibility to infection may be greatly increased, and the disease probably brought on by the above or other similar causes. The common gateway of introduction of the infection is either through the gastrointestinal tract or from the female reproductive organs.
A study of the micro-organisms and their modes of entrance is interesting and important, but cannot be given here in full. The most common of these are the bacillus coli communis, the streptococcus, staphylococcus, pneumococcus, and occasionally the gonococcus, with in rare cases the bacillus typhosus as well as the bacillus pyocyaneus.
It was at one time thought that any exposure of the peritoneum would result in immediate inflammation and probably, in death. Our present knowledge of sepsis, our access to reliable antispetic measures and perfect cleanliness have robbed surgical operations which invole the peritoneum of danger. At the same time we have learned that the peritoneum possesses in itself an inherent power to resist infection and to destroy micro-organisms and other infective elements which are brought in contact with it. In robust health this resistance is extreme, but any impairment of this vital resisting power, either by injury, by cold or by other local or constitutional derangement, will permit the development of the septic processes which the micro-organisms induce.
It will be seen that infectious disease of any organ contiguous to the peritoneum may impair the vitality of but a small portion of this serous membrane, but that through this small impaired portion the micro-organisms may be introduced, and either a local or general peritonitis result. The disease then is usually secondary. It follows acute stomach disorder, gastric ulcer or malignant disease. It results from enteric fever of any form, notably from catarrhal enteritis, colitis, and very frequently from appendicitis. Intestinal irritation in children from improper food, or, as in one of the author's cases, from eating a large quantity of grapes and swallowing the seeds, or the presence of worms, will induce it.
It results from purulent inflammation of the gall bladder, of the kidneys, or of the urinary bladder. It is common as the result of inflammation of the womb, fallopian tubes or ovaries, from direct septic invasion. This form of the disease, occurring subsequent to confinement, is designated as puerperal peritonitis. It is especially liable to follow severe or protracted labors, or those badly conducted, or those in which strict asepsis has not been observed. It also frequently follows abortion.
The disease occurs as the result of acute diarrhea, and may complicate the convalescence of measles or scarlet fever, although this is rare. Direct septic invasion may occur from gunshot, knife and other penetrating wounds, from surgical operations, and from burns which involve the abdominal walls. While it is frequently asserted that the disease follows gonorrhea directly, clinical observation does not confirm this theory.
Peritonitis occasionally occurs during the progress of severe fever, and especially if from any cause the fever follows confinement, when it may be plainly brought on by a severe nervous shock, or by extreme mental depression, grief, or a high degree of nervous excitability. This is often classed with the so-called hysteric peritonitis, which occurs at other times with women, and closely resembles the genuine form. In the hysterical form, however, the tenderness and pain complained of are not accompanied by the constitutional results which should accompany such severe pain. In most puerperal cases there are all the evidences of severe involvement, with adhesions or prostration and death. This may be explained by the sudden development of toxins from the presence of an elevated temperature, which, on its part, is brought on by the mental condition.
Peritonitis resulting from circumscribed or general tuberculosis is more apt to develop in a sub-acute or chronic form than to exhibit acute characteristic symptoms.
Symptomatology:—Acute, sharp pain in the abdomen is usually the first symptom of peritonitis. Accompanying this at once is chill, more or less severe. The patient becomes anxious and nervous, and fever rises rapidly. As the fever rises tenderness develops, in the local form over a circumscribed area, in the general form over the entire abdomen; or it may be localized at first, to become diffused later, until the entire peritoneum is involved. The temperature reaches the point of 104.5° or 105° F., sometimes within three or four hours. The pulse is hard, usually small, sometimes wiry and always rapid, beating from the first from 120 to 135 beats, and when the disease is at its height from 130 to 160 beats per minute. There is a pronounced shock to the nervous system, and by this the heart is immediately impressed. It becomes enfeebled, arterial tension decreases, and there is a marked change in the character of the pulse. In the serious stages the pulse is irregular and sometimes almost imperceptible. On the approach of a fatal termination it becomes thready and very rapid. The temperature taken in the mouth is observed to fall, but taken in the rectum or vagina it is found to continue high or increase a little. A cold perspiration covers the surface of the body; the respiration is rapid and shallow, as deep inspiration increases the pain; there is a shrunken condition of the face, with an anxious expression; the features have a pinched appearance; the nostrils are thin and drawn, the face becomes pale, or in some cases darkened or livid; the mucous membranes of the mouth are dry, the tongue is dry and parched, covered with a brown coat, and all secretions are scanty. The urine is clear, of dark color, and often temporarily retained, urination being impossible. In others there is frequent urination with local irritation.
The appetite is quickly lost, and nausea and vomiting occur, causing intense pain. There is hiccough, diarrhea and tympanites. This latter condition results from paralysis which may involve the intestinal tract, inducing obstinate constipation. The patient quickly assumes a supine position in the bed. So extreme is the abdominal tenderness that she cannot bear the weight of the bed clothes, and for the double purpose of removing this weight and reducing the tension of the abdominal muscles the thighs are flexed upon the abdomen. Every jar of the bed or movement of the clothes increases the pain.
These patients often become restless, excitable and develop an intense mental acuteness. There is agitation and anxiety and the reasoning powers are exaggerated. This may continue to but a short time before death. In other cases there is a very excitable delirium with extreme nervous irritation, while in still other cases no delirium may appear until a short time before death. The patient may then exhibit mild symptoms of delirium and gradually sink into a stupor, to be soon followed by coma.
Occasionally this disease results from the sudden introduction into the peritoneum, of pus from the rupture of an abscess, or from the introduction of the contents of the stomach or intestinal canal, from perforation, or from the rupture of a cyst which contains purulent material. When this occurs the onset of the disease is sudden, and shock with threatened collapse are among the first symptoms. There are cases distinctly septic in origin, which are characterized by an absence of pain, and which exhibit a distinctly high temperature at the onset.
Physical examination of the abdomen is almost impossible because of the exquisite tenderness. The abdominal walls are greatly distended and are firm or rigid. The tympanites obliterates the hepatic and splenic dulness, but dulness will be found in the dependent portion because of the gravitation of fluids.
Diagnosis:—The abdominal pain, rapidly developing tenderness, and sharp fever, are the pathognomonic phenomena of peritonitis. In the circumscribed form of the disease the pain remains local and the tenderness is distinctly circumscribed. There is seldom any difficulty in the diagnosis, and other diseases can be readily excluded by the absence of their characteristic phenomena.
Prognosis:—While this disease is a most serious one, it presents important specific phenomena, to which we have learned to apply reliable remedies, and thus our treatment has become certain and to a great degree satisfactory, enabling us to modify the serious or fatal prognosis given by the writers of the past. Where the cause is the evacuation of septic material into the peritoneum the results are much more serious, and a fatal termination can be anticipated. Where there is shock to the nervous system, tympanites and abdominal distention from paralysis, with a pronounced impression upon the heart and circulatory apparatus, the outlook is very grave.
Treatment:—The immediate demand in the treatment of acute peritonitis is the relief of pain. Most authorities advise the use of opium or the hypodermic injection of morphin for this purpose. I am convinced that this course should be avoided as often as possible, in all but the extreme cases, when opium may be given, as is advised farther on. At the onset the patient should have a hot mustard foot bath, which should be continued for from twenty to thirty minutes, and should drink hot infusions calculated to induce perspiration. Or she may take from ten to twenty drops of the fluid extract of jaborandi, one dose only. If the pain has already become so severe as to be increased by every movement of the patient, a large mustard poultice, made strong, should be applied warm over the location of the pain at least, if it does not seem practicable to apply it over the entire abdomen. At the termination of the foot bath, the patient should be put into bed and libradol should be applied over the entire abdominal surface. This application should be watched, as unlike other plastic dressings, it is highly medicated, and if too greatly prolonged will induce nausea and some depression. It will be tolerated by most patients for from four to six hours; in extreme cases, eight hours. Heat should be applied external to it, as when so applied its influence is exercised in a shorter time. When removed, antiphlogistine should be applied hot and in a careful manner, where its weight is not greatly objected to, and this should be kept hot continuously for from twenty-four to forty-eight hours.
These preliminary measures will usually cause a temporary abatement of the pain and will permit the use of bryonia, allowing the necessary time to obtain its characteristic influence upon the developing inflammation. This agent allays the pain in a manner much more satisfactory than that accomplished by opium or morphin. It is specific to inflammation in the serous membranes. It can be persisted in however high the temperature or however severe the constitutional impressions. It promotes resolution, contributes to a return of the normal conditions of the capillary circulation in the membrane, antagonizes an outpour of the usual exudates, and especially inhibits the breaking down of tissue and the formation of pus. It must be used with confidence to be appreciated, as it seems to include in its influence all of the pathological processes involved in the inflammation, positively restoring the inherent vital resistance of the membrane to microorganisms.
Bryonia is a direct sedative to the fever processes, and often controls the temperature without the assistance of other remedies. But I have usually found marked indications for the use of aconite, and have prescribed the two remedies together. These are a tendency to dry skin, dry mucous membranes and a sharp, hard, quick pulse. There is a marvelous harmony in the action of the two remedies, and while operating upon different conditions, each seems to enforce the action of the other.
At the onset of this disease, during the period of chill, belladonna in small doses frequently repeated will antagonize the processes of inflammation and exercise a powerful influence in equalizing the circulation. But this remedy will not be indicated when the disease is fully developed.
Asclepias, in its influence upon the serous membrane, is closely allied to bryonia. The two remedies are given together in pleuritis with striking results, and in peritonitis much the same results may be accomplished. I believe in administering it in rather full doses, from five to eight or ten drops of the specific medicine every hour.
If the pain is held in abeyance long enough to obtain a full influence from bryonia, or from bryonia in conjunction with the remedies just named, it may not return at all. I have observed this result from bryonia in many cases, and am confident of this influence of the remedy. Consequently, we have no use for special pain-relieving remedies, which obscure or mask the manifestations of the disease and are thus apt to mislead the prescriber, while they exercise but little curative influence. There is an occasional case in which the measures above suggested will produce no influence upon the pain from the first. The influence of the pain is clearly detrimental. I believe its impression upon the nervous centers is such as to retard the full physiological influence of bryonia and the other specific remedies. I, therefore, have been in the habit of using opium in frequently repeated small doses. I advise two drops of the deodorized tincture every hour in the less severe cases, and in the extreme cases five drops every hour, until I am able to observe a reasonable abatement in the pain, when the dose is reduced one, two or three drops. This course is preferable to repeating the full dose, which some advise, at greater intervals, intervals of two, three or four hours. I prefer the gradual reduction in the size of the dose, until the soreness as well as the pain has somewhat abated, when I endeavor to drop the opium entirely and depend upon the bryonia.
If at the onset there is a great degree of nervous excitement, I would, instead of the aconite, prescribe gelsemium with the bryonia, until the nervous symptoms have abated. At that time the indications for both the aconite and gelsemium may have been overcome and dependence can then be placed upon the bryonia alone again.
At times as the disease progresses the temperature remains high, the pulse becomes hard, or small and wiry, there is restlessness and persistent loss of sleep, with a sharp pointed tongue and dark colored mucous membranes. These indications demand rhus toxicodendron. Its influence will be prompt and satisfactory.
I have seldom found indications for veratrum in this disease which cannot be better met by the remedies above named. However, in markedly sthenic cases, at the onset, there is a time when the large, full, strong, but rapid pulse will indicate this remedy, and if given in pronounced doses for a few hours, while its influence is very closely watched for nausea or other sign of depression, it may exercise a very positive influence in preventing or retarding the development of the disease.
Gastric complications, with dark mucous membranes and dry tongue with a tendency toward sordes, may be met promptly with doses of from five to ten drops of dilute hydrochloric acid every three hours, in an ounce or two of water. When the mucous membranes are pale and the tongue is thick and broad, and covered with a dirty coat, the sodium sulphite is indicated; if the tongue is moist and coated with a dense white coat, calcined magnesia or sodium bicarbonate should be given for a short time.
The condition of the bowels must receive attention, but irritating cathartics must be avoided. A mild saline laxative of magnesium sulphate or calcined magnesia will be of service to unload the primae viae at the onset. This effect can be sustained by the action of small doses, about fifteen grains, of the sulphate of magnesium and nitrate of potassium; combined, or by the use of from sixty to eighty grains of the effervescing sodium phosphate once or twice a day. However, I have noticed no bad results after thoroughly cleansing the intestinal tract at the onset and after each movement, in permitting the bowels to go two or three days at a time without movement. But this is theoretically objectionable, to the patients and to a consulting physician as well; consequently a colonic flush each day is preferable. Other cases will do well in this disease, as they do in appendicitis, upon the free use of sweet oil during the entire course of the disease. As the strength of the patient fails, an enema once or twice each day of the normal salt solution should be used. Extreme tympanites may be temporarily reduced by the use of an injection of half a dram of the oil of turpentine in from two to three quarts of warm water. When with tympanites there are evidences of impairment of the blood, such as dark, dry mucous membranes with a dark brown or black coat on the tongue and sordes upon the teeth, turpentine should be given internally in from two to five minim doses in an emulsion every two or three hours. This may be continued for several days. Where tympanites is present, with more or less of an atonic condition of the gastrointestinal tract, specific xanthoxylum will be of much service in doses of two or three drops given every two hours. It was at one time common practice to apply turpentine stupes over the abdomen whenever tympanites was present, and the results would certainly justify that procedure at any time if antiphlogistine or other poultices of that kind were not sufficient. I think there are times when turpentine is the superior application, especially if the weight of a poultice is objectionable. With the above indications echinacea will be of service also in preventing the important changes which are taking place in the blood.
When peritonitis is distinctly local or circumscribed, the application of libradol over the inflamed areas may be continued for perhaps twenty-four hours. It should then be removed, but may be subsequently replaced for an equal length of time, without inducing nausea; or the acute pain may be relieved by the application of a strong mustard paste. The local inflamed area may be covered with a hot application, which should be persisted in until the tenderness and pain have abated. Other conditions which may appear which are similar to those occurring in general peritonitis should be treated precisely as advised for that form of the disease.
For the persistent nausea I have much confidence in the use of equal parts of bismuth and ingluvin in mint water or in cinnamon water. Thirty grains of each in three ounces of water may be shaken well and administered in teaspoonful doses, every twenty or thirty minutes, for two or three hours, when the vomiting will cease for perhaps twenty-four hours.
The feeding of the patient is an important consideration in the treatment. If possible, they should have milk alone, adminstered in small quantity at regular intervals, or an egg may be beaten with the milk and a teaspoonful or two of this may be given every half hour or hour. Where there are indications for the use of acids, buttermilk or whey will be most kindly received, and will be found very nutritious. Kumyss is excellent during convalescence. In other cases it may be necessary to peptonize the milk, or where the stomach refuses to receive food, it may be given a complete rest, and all nourishment may be given for a short time per rectum.
Thirst is a most troublesome symptom in peritonitis, whether nausea exists or not. This may be relieved by the taking of small pieces of ice, or by an occasional half tea-spoonful of ice-cream, which also exercises its characteristic nutritional influence.
Convalescence will demand the utmost care and personal supervision. Every indication reappearing must be met at once, and restoratives must be selected with discretion, as suggested by the existing conditions.
The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.