Chronic inflammation of the peritoneum may exhibit itself in several distinctive forms. The most common of these is that known as adhesive peritonitis, which is usually circumscribed in character, and is found in a portion of the peritoneum which is contiguous to some organ in which previous inflammation has existed; or the condition may follow as the sequel of an acute attack of peritonitis. In this form the contiguous layers of the peritoneum adhere to each other, or the peritoneum becomes attached to folds of the intestine. This form of peritonitis is common in gynecology, following inflammation of the tubes or ovaries. Another form is that which is known as the diffused form. This is similar to that which develops from tuberculous inflammation. It results in agglutination of the peritoneal walls or of the coils of the intestines, and causes considerable thickening of the parietal layer of the peritoneum, which as it is folded over the other organs causes constriction.
Another form is the proliferative form. In this there is thickening of the peritoneum, with the secretion of a large quantity of fluid into the abdominal cavity. The omentum is thickened, and assumes the form of a hard mass or band across the upper portion of the abdomen. There is but little if any adhesion in this form, as this is prevented by the presence of the fluid. However, local adhesions are not impossible, by which portions of the fluid may be walled off from other portions, forming pockets. There may be present with this cirrhosis of the liver or kidneys, and occasionally of the stomach. This is especially true when the disease occurs in those who are addicted to the use of alcohol. The external evidences closely resemble those of tubercular peritonitis, which is a distinct form of the disease, but presents no phenomena very different from those just described. The tubercular nodules which may form, are diagnosed by microscopical examination, or by a history of tubercular development elsewhere in the system.
Virchow and Friederich describe a condition designated as chronic hemorrhagic peritonitis, in which from traumatic causes, or from the persistent use of the trochar, or other repeated injury of the membrane, the peritoneum is covered with an adventitious membrane, through which there is an extravasation of blood.
Etiology:—This disease follows acute attacks, or results from the persistent presence in the abdominal cavity of a foreign growth. It follows chronic rheumatism, and is present often where there is a cancerous or tubercular diatheses.
Symptomatology:—Persistent local soreness, hardly noticed at first, but gradually increasing, is an early symptom of chronic peritonitis. Accompanying this is impairment of the digestion, loss of appetite, emaciation and constipation, except perhaps in tubercular cases. These patients are often in a fairly well nourished condition. There is an irregular fever, but some elevation of the temperature is nearly always present. The pulse is rapid, small, and easily compressible. The patient cannot bear physical exertion, gets easily "out of breath," and finally becomes irritable, despondent, and the face has a look of anxiety. The nervous symptoms are not necessarily pronounced. Where there are menstrual or uterine complications, hysterical symptoms may develop. As the disease progresses and there is a pronounced disturbance of the nutrition, the patient becomes emaciated and the abdomen becomes prominent. Occasionally jaundice will develop, and if the liver or renal complications are severe, there will be distinctly pronounced ascites.
Diagnosis:—The history of persistent tenderness, with hardness of the abdominal walls, continuing after an acute attack of peritonitis, is suspicious of the insidious development of the chronic form of the disease. In one of the author's cases, in a young woman, the evidences were conspicuously those of tubercular peritonitis. No tubercular development could be diagnosed, and the condition had a favorable termination in reasonable health without an operation.
Treatment:—I am positively in favor of persistently antagonizing the fever processes in this disease by the use of specific remedies. My experience has confirmed the benefits of so doing. I have given aconite and bryonia in very small doses for from four to eight weeks at a time, and have observed results which I believe I am justified in attributing to the action of the remedies, as they were in direct line with hoped for and anticipated results. These remedies retard exudation, suppuration, adhesion, induration and hypertrophy. They promote tone and power in the arterial capillaries and are opposed to blood stasis. This characteristic influence through their influence upon the capillary circulation antagonizes the chronic inflammatory processes, promotes absorption of the inflammatory products and hastens resolution.
Other remedies of importance are echinacea, which antagonizes the growth and development of the toxins and their influence upon the blood; phytolacca, which promotes the action of the lymphatic glands and assists in the removal of morbific products; the iodids, which have a general alterative influence and stimulate resorption of fluids. Remedies directed to the gastrointestinal tract will be of much service in relieving pain and promoting normal functional activity. Hydrastis and collinsonia are first in the list for this influence. Specifically colocynth is indicated where there are constant, quick, shooting pains in the intestinal tract; dioscorea where there are cramp-like pains in the stomach, or bowels. Where persistent diarrhea is present, with constant nagging, irritating, colicky pains, I have obtained superb results from the persistent use of two grain doses of ammonium chlorid in solution with one-thirty-second of a grain of morphin, to mildly quiet increased peristalsis. One severe case obtained immediate benefit and ultimate cure from this simple combination.
The diet of these patients should be highly nutritious, concentrated, and should cover a limited number of articles. Highly seasoned foods, pastry and acid foods with cured meats should be excluded. Out of door exercise and freedom from care and worry should be insisted upon.