Acute General Peritonitis.
Definition.—An acute inflammation of the peritoneum, either local or general.
Acute General Peritonitis.
Etiology.—Though there are many possible causes giving rise to peritonitis, the most common and frequent mode of infection can be traced to one of two sources—gastro-intestinal, and the female genital organs.
Ulceration of the stomach or of the bowel, either due to typhoid fever, dysentery, appendicitis, intestinal obstruction or a high grade of enteritis, induces the disease.
A premature or a prolonged and difficult labor not infrequently leaves an infected genital tract, to be followed by metritis, endometritis, ovaritis, and peritonitis.
Disease of the bladder may also be responsible for this affection. Tubercular ulcerations and malignant affections not infrequently cause peritonitis, while abscesses of the liver, impaction of the hepatic ducts, nephritis, and splenitis are to be reckoned among the causes.
Penetrating wounds of the abdomen, or even surgical operations, open the way for the introduction of septic processes, and peritonitis follows. Pleuritis and endocarditis may give rise to the affection, through the lymph vessels of the diaphragm.
The micro-organisms most commonly associated with peritonitis are the streptococcus pyogenes, the bacillus coli communis, and the bacillus tuberculosis, though a number of others are found. Chronic irritants may give rise to the disease, as where a perverted bile irritates serous surfaces, or the toxins produced from the various bacteria. The disease may be primary or secondary, though rarely the former.
Pathology.—Peritonitis, like pleuritis or pericarditis, manifests a variety of conditions, depending upon the form or type of the inflammation, and may be either dry, plastic, or fibrinous, sero-fibrinous, sero-purulent, or hemorrhagic.
If the inflammation is diffuse, we find the parietal layer of the peritoneum, -as well as the outer surfaces of the intestines, red, injected, and swollen, and the serous membrane clouded, due to the presence of a fibrinous exudate and to desquamation of the epithelium. As a result of this fibrinous exudate, adhesion takes place between coils of intestine, or between intestines and other viscera.
There is nearly always present more or less fluid in the abdominal cavity, which varies in character. It may be small in quantity and of a serous or sero-fibrinous character, though, if due to intestinal perforation or puerperal conditions, it is apt to be purulent in character.
Where the inflammation is severe and prolonged, the intestines share in the inflammation, with thickening of their walls.
In circumscribed or local peritonitis, adhesions limit the extent of the inflammation, and it is often known as adhesive peritonitis.
Symptoms.—Usually chilly sensations, or a marked rigor, announce the presence of peritonitis. At the same time the patient experiences severe abdominal pain; at first local, most frequently in the right side or in the pelvis, but it soon becomes general, involving the entire abdomen. The temperature rapidly reaches 103°, 104°, or 105°; the pulse is small, frequent, and wiry, varying from 120 to 160 beats per minute. The respiration is shallow, hurried, and restricted to the thorax—thoracic breathing.
The tongue, at first white and pasty, soon becomes dry, and of a red or brown color. Hiccough is a common and distressing symptom. The position of the patient in bed is characteristic; he lies on his back, with his limbs flexed to relieve abdominal tension. The abdomen is exquisitely sensitive, and often the weight of the bedclothes causes much suffering.
The abdomen is distended and drummy, sometimes enormously. Any movement of the body, such as coughing, sneezing, or even a full respiration, increases the sufferings of the patient.
Nausea and vomiting is an early symptom, the latter causing great pain. In the early stage of the disease, diarrhea is a frequent symptom, but soon gives way to obstinate constipation. Micturition is frequent, the urine being scanty and high-colored.
The appearance of the face is somewhat characteristic. There is an anxious look, the nose is pinched, the eyes somewhat sunken, and the nose and ears are inclined to be cool.
There is seldom delirium, save in the advanced stages, and occurs mostly in fatal cases, and in these it soon gives way to stupor, and finally coma.
Physical Signs.—Inspection reveals a marked distention of the abdomen, and palpation shows the abdomen rigid and extremely sensitive to the touch.
Percussion causes much suffering, and reveals marked tym-pany, the liver and spinal dullness being obliterated. If there be much effusion of fluid, there will be dullness in the most dependent portion of the abdomen, unless the gaseous distention be excessive, when the pressure of fluid may be hard to detect.
In fatal cases, the surface temperature usually drops, though, if the temperature be taken by rectum or vagina, it is very high; the respiration becomes feeble and shallow, the pulse small and thready; the patient sinks into a profound stupor, to be soon followed by death.
Where the attack is due to a perforation, the first symptoms are generally those of collapse, to be followed by those already mentioned.
Diagnosis.—This is not usually difficult. The continuous pain and tenderness of the abdomen, the marked distention, the marked increase in temperature, the frequent, wiry pulse, shallow, thoracic respiration, hiccough, nausea, and vomiting, diarrhea, followed by constipation, the characteristic pinched and anxious expression, and symptoms of collapse, are pathognomonic, while a physical examination confirms the above, and relieves any doubt that may have existed.
Prognosis.—Acute general peritonitis is an extremely grave disease, and the prognosis should be very guarded. Death may occur within forty-eight or seventy-two hours, and most fatal cases within ten days. Great abdominal distention, with extreme tenderness, shallow, hurried breathing, small, wiry pulse, pinched features, and coldness of surface, suggest an unfavorable termination.
Treatment.—Although a grave disease, careful medication will succeed in restoring a good per cent of our cases. If we remember that we have an inflammation of serous tissues not unlike pleurisy or pericarditis, the treatment will be more successful.
Select the appropriate sedative,—veratrum if the pulse be full and strong, a rare case; or aconite where the pulse is small and rapid. To these we add the indicated remedy. The sharp, lancinating pain will call for bryonia as in pleurisy. Abdominal soreness will call for dioscorea. The wiry pulse, with inability to sleep, calls for rhus tox. Where the patient is restless, and there is cerebro-spinal irritation, gelsemium in full doses is an excellent remedy. Colocynth must not be forgotten for the sharp, spasmodic pain.
If the tongue be dry, red, or brown, with sordes on the teeth, hydrochloric acid will give the most satisfactory results; but where the tongue is moist and dirty, sodium sulphite will be the better remedy. For bad odors, potassium chlorate has no superior. If there be marked nausea and vomiting, small bits of ice in the mouth, or a little mint-water and bismuth, will frequently overcome it.
The abdomen will be so sensitive that only light-weight applications will be allowed. Cloths wrung out of hot or cold water should be given a trial; in most cases, the hot will give greater relief. Some cases will be benefited by the local use of lard and turpentine. One of the best of local applications is libradol. It not only possesses anodyne properties, but is a relaxant as well.
A fresh application should be made every twenty-four hours. If the disease is due to puerperal conditions, uterine irrigation will be highly beneficial, if too much force be not used. Do not elevate the fountain higher than is necessary to allow the fluid to flow into the womb and out again. A weak solution of potassium permanganate will give good results.
Enemas of normal salt solution will be helpful. Where the distention of the bowel is excessive, tincture prickly-ash berries, two drams; turpentine, fifteen drops; and water four ounces, will be a good enema.
Albumen water or sherry whey, given in small quantities, is usually well received by the stomach. Where nourishment can not be taken by mouth peptonized milk and small quantities of salt solution should be given per rectum.