the records were probably made by a number of different persons, and
persons of varying views and varying capacity and judgment. It is
possible that the quotation may embrace some of the changes already
referred to as the consequences of peritonitis. It does embrace the
cases {1137} "when inflammation of the serous membrane occurs in the
course of albuminuria, pyæmia, puerperal fever, erysipelas, etc." It
also includes "peritonitis caused by general nutritive changes in the
system," as seen "in struma, cancer, etc.," "comprising also those
cases in which the circulation of the peritoneum has been so altered by
continued hyperæmia (modifying its state of growth) that very slight
existing causes suffice to excite mischief, as in peritonitis with
cirrhosis, disease of the heart, etc."
With these explanations the statement differs widely from what it would
seem to mean without them. It is far from saying that peritonitis
always follows some abdominal lesion and is caused by that lesion.
Habershon's paper was published twenty-three years ago, and during all
these years the curative treatment of peritonitis, to which the paper
itself gave currency, has enabled us to study our cases after recovery
as well as before the sickness, and it can hardly be doubted that a
much larger proportion of the cases are primary and idiopathic than
either Louis or Habershon found reason to admit. That a large number
are produced by preceding lesions and constitutional conditions no one
will be likely to doubt.
Among the 500 post-mortem examinations of peritonitis reported by
Habershon, he found preceding disease or injury recognizable in the
abdominal cavity in 261. The following is his table, viz.:
From hernia, of which 19 were internal obstruction . . . . . . . 102
From injuries or operations . . . . . . . . . . . . . . . . . . 35
From perforation of the stomach, ileum, cæcum and appendix,
colon, etc. (other 13 mentioned with hernia, or with cæcal
disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
And leading to fecal abscess (2 otherwise mentioned) . . . . . . 17
From typhoid ulceration without perforation . . . . . . . . . . 5
From disease or operation on bladder and pelvis, viscera, etc. . 42
From disease of the liver and gall-bladder . . . . . . . . . . . 11
From acute disease of the colon (3 others enumerated with
perforation) . . . . . . . . . . . . . . . . . . . . . . . . . 3
From disease of the cæcum or appendix (9 others previously
mentioned) . . . . . . . . . . . . . . . . . . . . . . . . . . 3
---
261
Habershon says that in the (his) second and third divisions of the
cases the causes were as follows:
From Bright's disease . . . . . . . . . . . . . . . . . . . . . 63
From pyæmia, 13; erysipelas, 5; puerperal fever, 10; with
pneumonia, 3 . . . . . . . . . . . . . . . . . . . . . . . . . 31
From strumous disease . . . . . . . . . . . . . . . . . . . . . 70
From cancerous disease . . . . . . . . . . . . . . . . . . . . . 40
From hepatic disease . . . . . . . . . . . . . . . . . . . . . . 27
From heart disease . . . . . . . . . . . . . . . . . . . . . . . 9
---
240
I have drawn thus liberally from Habershon's paper because it is the
only paper that I know, in any language, founded on the analysis of a
large number of cases (for five hundred post-mortem examinations is a
large number for a disease no more frequent than peritonitis), in the
belief that he dealt with facts and that his conclusions must be of
great value. He may differ with other physicians regarding what
constitutes strumous disease and in the agency of heart disease. He may
have mistaken coincidence for consequence, but the paper bears the
marks of honesty and good faith from the beginning to the end.
In Habershon's second division, under which he ranks the cases of
{1138} peritonitis caused by "a changed condition of the blood," he
ascribes 63 to albuminuria. Every physician knows how often meningitis
or pericarditis or pleurisy may occur under these circumstances,
especially in young persons; but, for myself, I cannot but express
surprise at these figures. In one capacity or another I have been
connected with large hospitals for forty-eight years, and have seen
many cases of albuminuria in private practice, and can recall but few
instances in which kidney disease, excepting cancer and other tumors,
has terminated in peritonitis. In modification of this statement,
however, it is proper to add that the hospital physician cannot know
how half the diseases he treats terminate, on account of the American
plan of interrupted service, and even less can he know of the mode of
death in cases which he sees in consultation. Even with this admission,
from my standpoint it is not easy to believe that one-eighth of the
cases of peritonitis are caused by albuminuria.
The word pyæmia used by Habershon, it seems to me, ought to be replaced
by septicæmia, and it has been by many of the profession. Sédillot many
years ago proved that laudable pus injected into the blood-vessels of
the dog produced no signs of disease, but that septic pus, so used, was
followed by grave symptoms, even death. Among the author's cases
thirteen were associated with the septic poison. He also found five
which he thinks were independent of erysipelas. One in one hundred is a
proportion hardly large enough to establish the relation of cause and
effect against the chances of concurrence.
I can make a remark with reference to the inquiry by C. Dubacy in the
October number (1881) of the _American Journal of Medical Sciences_,
whether diphtheria produces peritonitis. When diphtheria became
epidemic among us in 1860 or 1861 for several years, I saw a great deal
of it, but did not recognize any relation between it and peritonitis.
The relations of hernia, injuries, and operations to peritonitis need
no commentary.
Perforations of the alimentary canal may require some illustrative
statements. These occur most frequently in the vermiform appendix of
the cæcum, and are almost invariably caused by some irritating
substance imprisoned in its tube. In some cases it is a seed of some
fruit, as the orange or lemon; in others, a cherry-pit; in one that I
remember it was a small stone, such as is sometimes found in rice; in
others, a hard fecal concretion; in one, a child, a singular formation:
a strawberry-seed was the centre; around this a layer of fecal matter,
around the fecal matter a calcareous layer, on this, again, a fecal
layer, and so on to the number of six layers, the external one being
calcareous. This body was about one-fourth of an inch in diameter, and
may have been years in forming. In this connection I may state, per
contra, that I am informed that in a pathological museum in Boston is
preserved an appendix that contains, and did contain, a large number of
bird-shot, which did no mischief except to enlarge the appendix. This
was from the body of a man who had shot and eaten many birds. My
observation has led me to the belief that a large proportion of the
cases of peritonitis occurring in children are due to perforation of
the appendix.
Of the diseases of the liver producing acute diffuse peritonitis, the
foremost, I think, is abscess, single or multiple. The different modes
in which gall-stones may produce it may be illustrated by the following
{1139} cases: (1) A lady died of acute peritonitis. At post-mortem
examination a large abscess was found, bounded above by the liver, in
other directions by adherent intestines; it contained nearly a quart of
pus: at the bottom of the sac was a single gall-stone, very large and
very black; the gall-bladder was perforated and very much shrunken. The
gall-stone had caused an ulceration of the gall-bladder, but none of
the intestines, in this respect differing from the process known as
painless transit of a gall-stone. So the calculus caused the abscess,
and the abscess caused the general peritonitis. (2) A lady between
fifty and sixty years of age had an attack of gall-stone pains; she had
had them before. In a few hours symptoms of peritonitis were manifest,
and she died. The post-mortem examination showed the ductus cysticus
was ulcerated and perforated. Two gall-stones of large size had been
formed in the gall-bladder, and had been pushed forward into the duct
about halfway to the common duct, leaving it enlarged as they advanced.
The foremost one had caused an ulcer on the anterior or lower side of
the duct, and bile had escaped, staining all the right half of the
abdominal cavity, and throughout this half only the parts were covered
with false membrane and stained with bile.
These cases are not so very uncommon. John Freeland of Antigua had a
patient, a colored woman sixty-five years of age, who had been
suffering from intermittent fever, gastric disorder, and retching. In
one of the vomiting spells she experienced great pain, which, being
relieved by an opiate, soon returned and was attended by tympanitic and
tender abdomen. Death occurred in collapse about eight hours later. The
cavity of the abdomen was found filled with blood and bile, the
intestines inflamed and gangrenous in spots, and there was general
peritonitis. The gall-bladder was empty; the hepatic duct was
lacerated, and contained pouches in which gall-stones were encysted.
One of these bags was lacerated. This laceration was surrounded by
evidences of recent inflammation, and caused the general
peritonitis.[2]
[Footnote 2: The _Medical Record_, Dec. 9, 1882.]
The perforations of the stomach which I have seen have been attended by
little inflammation of the peritoneum. Death has followed this accident
in twenty to thirty-six hours. There has been little pain, little
tumefaction of the bowels, little tenderness, but a sense of sinking
and a peculiar feeling at the stomach which the patient finds it
difficult to describe.
The ulcers of dysentery do at times perforate all the coats of the
colon, and yet do not with any uniformity cause general peritonitis;
but as the destructive process approaches the outer covering the latter
becomes inflamed, and lymph enough is effused to close the opening and
prevent the escape of the contents of the intestine; so that, while
perforation is not uncommon, I have rarely seen diffuse peritonitis
accompanying dysentery.
Habershon reports 5 cases in which incomplete typhoid ulcers of the
intestines caused peritonitis, and 15 from the complete perforation. I
believe that the physicians of this country and those of France have
found the complete perforation much the most common.
I do not remember to have seen fecal accumulation in the intestines
produce peritonitis at all general. I did see, years ago, a man of
middle {1140} age in whom fecal impaction in the ascending colon had
caused destruction of all the layers of the abdominal wall on the right
side, so that the contents of the intestine were exposed to view in a
space of three inches by two. This implies that there had been
peritoneal inflammation enough to seal the intestine to the abdominal
wall on all the borders of this extraordinary ulcer. The man recovered
in about six months, and returned to his business.
The inconsiderable operation of tapping for abdominal and ovarian
dropsy has sometimes been followed by acute peritonitis. In the early
part of my professional life I met with several such cases, and have
witnessed the same from time to time since. These were mostly cases of
dropsy from cirrhosis of the liver. Habershon found 5 such cases, and 7
in the tapping of ovarian cysts.
The rupture of ovarian cysts has produced peritonitis, but in a larger
number of cases such rupture, even when the result of violence, has not
led to inflammation; but the kidney secretion has been greatly
augmented and the fluid absorbed, so that the rupture has been
beneficial rather than harmful.
Tumors, particularly those of a malignant character, are apt to grow to
the surrounding structures by adhesions the result of chronic
inflammation, but now and then they provoke an acute attack which
becomes general. Benign tumors may, in rare instances, do this. In one
case a man died of acute peritonitis, and the examination showed that a
tumor noticed before death, a very large serous cyst standing out of
the left kidney, downward-forward, was the only lesion that antedated
the inflammation.
Infiltration of urine, in any of the several ways in which it can reach
the peritoneum, is a cause of peritonitis. Pelvic cellulitis may also
be a cause, though twenty or thirty cases in succession may run a
favorable course with no secondary lesions; it is still recognized as
one of the occasional causes of peritonitis.
Among the rare causes of diffusive peritonitis is perforation of the
intestine by lumbricoid worms. In such cases the product of the
inflammatory action is apt to be sero-purulent, with but a limited
amount of fibrin. E. Marcus reports such a perforation, and it was
called by Peris ascaridophagie. The worms were apparently not found in
the peritoneal cavity, but in the intestines. The perforation had
bloodless edges, which lay quite close upon one another, as if they had
been separated by a piercing action of the attenuated extremity of the
parasite not eaten through.[3]
[Footnote 3: _N.Y. Med. Journal_, Jan. 27, 1883.]
Lusk finds that certain vaginal injections excite a local peritonitis.
Sentey gives the details of a case in which a midwife undertook to
procure an abortion by the douche. She used a tube that was large with
a spreading mouth or opening, which probably received the neck of the
uterus in such a way as to prevent the return of the water. It was, in
consequence, forced into the uterus and through one of the Fallopian
tubes into the peritoneal cavity. By this a rapidly-fatal peritonitis
was developed. He refers to two other similar cases. It would seem that
this mode of procuring abortion can be frightfully misused, however
safe it may be in skilful hands.
There is a word still to be said regarding the difference between
peritonitis produced by wounds, operations, violence, and internal
growths, or {1141} what, with a little liberty, may be called traumatic
causes, and that which arises spontaneously or without recognizable
cause. The first shows a tendency to limit itself to the immediate
neighborhood of the injury, and more frequently does not become
general; while the latter spreads pretty quickly over the whole extent
of the peritoneum.
SYMPTOMS.--There is, perhaps, no grave disease whose symptomatology is
more easily interpreted, in which the diagnosis is more easily made,
than the average case of acute diffuse peritonitis. Yet there are
obscure cases which it is difficult to recognize.
In a well-marked case the first symptom is pain. Chomel and even some
later writers believe that chill precedes the pain, but to the best of
my recollection it has not generally so occurred to me; and the
question arises, Have they kept the symptoms of puerperal peritonitis
separated from those of simple peritonitis?
The pain is first felt in a somewhat limited space in the abdomen, and
pretty rapidly spreads, so that it is soon felt in every part of the
bowels. It may remain greatest in the part where it first began, but
there are many exceptions to this statement. As the disease advances
the pain and tenderness become more marked, and the patient will try to
diminish the tension of the abdominal walls by lying on his back and by
bending the hip- and knee-joints, often also for the additional purpose
of lifting the bedclothes from his abdomen. Often the patient will
resist the physician's movement to examine his bowel with the hand. In
the last few hours of life the pain ceases.
The pulse in its frequency follows the advances in the disease. At the
onset it is not much accelerated, but in two or three hours it may
reach 100 to 120 in the minute. Besides becoming more frequent, it
becomes smaller in volume and more tense. Toward the end of a fatal
case it may reach 140 to 160 in the minute and be very small.
In the early hours of peritonitis the bowels begin to swell, and
percussion shows that the swelling is caused by gaseous accumulation.
This increases as the disease goes on, so that in some the bowels
become greatly distended--so much, indeed, as to diminish the thoracic
space and interfere with the respiration. As the disease advances the
tympanitic resonance may give place to dulness on percussion on the
sides and lower part of the abdomen. This is due to fluid effusion.
Before the introduction of opium in the treatment of peritonitis the
green vomit was a marked feature of the disease. It occurs in other
conditions, but rarely, and its occurrence in this disease was so
common that it was regarded as almost diagnostic. The fluid vomited is
of a spinach-green color, and the color is probably derived from the
bile; at least, I have examined it repeatedly for the blood-elements,
and have not found them. In these days this symptom of peritonitis is
not often observed.
Constipation is absolute in uncomplicated peritonitis of ordinary
severity, and I believe is caused by a temporary paralysis of the
muscular layer of the intestine. It has already been stated that the
blood-supply of the peritoneum is through vessels whose capillaries are
shared by that membrane and the tissues which it covers. Inflammatory
action in the peritoneum of average severity would naturally extend to
this muscular layer and render it inactive. When the inflammation
abates it recovers its contractile power. Thus, the intestines become
entirely insensitive to {1142} cathartic medicines. This fact is not
observed in puerperal peritonitis, probably because the large share
which the uterus takes of the disease may act, in some degree, as a
derivative; and then, so far as I know, the muscular layer of the
intestines does not undergo the change of color and appearance in the
latter disease that has been observed in the former. This obstinate
constipation has been noticed from the first discovery of the disease,
and during forty years in the first part of this century many
physicians believed that if they could overcome it their patients would
recover. The present interpretation of this conviction is that if
catharsis, which was very rarely effected, did precede recovery, the
disease was not of a grave type--if, indeed, it was peritonitis at all.
Sometimes peritonitis occurs in the course of a diarrhoea; then the
constipation is not at once established, but the symptoms of the two
diseases concur for one or two days, when the diarrhoea ceases.
Abdominal respiration ceases when peritonitis is established, either
because the movements of the diaphragm produce pain or because the
diaphragm is partly paralyzed, as is the muscle of the intestines. Then
the gaseous distension of the bowels obstructs the action of this
muscle. As a clinical fact it is important, and has often helped me in
a diagnosis. Another kindred fact is that all the indications of
peristaltic action cease. I have a great many times placed my hand on
the abdomen and patiently waited for a sensation that would be evidence
of intestinal movements, but did not discover any--have placed my ear
on the surface of the abdomen, and have long listened for the gurgling
which is so constant in healthy bowels, and have listened in vain. In
this respect my observations differ from those of Battey, who reports
that he has heard the friction of the newly-made false membrane in
respiration, while I concur with him in the statement that the
sensation of friction can be felt by pressure of the ends of the
fingers into the abdominal wall so as to produce indentation. It should
be said regarding the friction sound in respiration that Battey has the
support of Chomel, and he in his turn quotes Barth and Roger; so that
there may be in this sign more than I have thus far found. (See case
hereafter related.)
The temperature of the body is not, considering the extent of membrane
involved, remarkably high. I have recently attended a most
carefully-observed case in which the temperature never rose above 104°
F. It falls below the temperature of health as the disease approaches a
fatal termination.
From the time this disease was recognized as a separate and distinct
affection the countenance has fixed the attention of writers. The face
is pale and bloodless and the features pinched, and the general
expression is one of anxiety and suffering. I do not remember to have
seen a flushed face in peritonitis, although the degree of paleness
differs in different patients.
The mind is almost always clear, unless disturbed by the medicines used
in the treatment. Yet cases are recorded in which a mild, and still
more rarely a violent, delirium has been noticed. Subsultus tendinum,
and even convulsions, have been witnessed, but whether these symptoms
belong to the peritonitis or to an accompanying uræmia has not received
the attention of those who have witnessed them.
The urine is usually scanty and high-colored, but it does not often
{1143} contain either albumen or casts. This statement is presumably
untrue of the cases in which Bright's disease preceded the peritonitis
and is supposed to be the cause of it--a variety of the disease with
which I have already declared my scanty acquaintance. The urine is
often voided with difficulty, and sometimes retained, so that resort to
a catheter becomes necessary.
The symptoms of this disease are not invariable. In one case the
inflation of the bowels is only enough to be perceptible; in another,
as I have said, it becomes a distressing symptom, while in most the
bowels are obstinately constipated. A case may now and then occur in
which evacuations can be procured by cathartics. Pain is regarded by
all physicians as the most constant symptom, and it has existed in
every case that I have seen, or at least tenderness; but the late
Griscom stated to me that a man once came to his office for advice in
whom he suspected peritonitis; but the man asserted that he had no
pain, and the doctor placed his fist on the abdominal wall and pushed
backward till he was resisted by the spinal column, the man asserting
that the pressure did not hurt him; yet he died the next day, the
doctor declared, of peritonitis. This may be credible in view of the
fact that absence of pain in puerperal peritonitis is not very
uncommon. The green vomit, which was expected in all cases forty years
ago, for the most part, as I have intimated, disappears under the opium
treatment. There are persons in whom peritonitis does not accelerate
the pulse beyond 100 beats in the minute. The pain, in rare cases,
remits and recurs with some degree of regularity, in this respect
resembling intestinal colic. Andral reports such a case; I have also
witnessed it.
MORTALITY.--Up to the time when the opium treatment was adopted,
peritonitis was a fearful word; a large proportion of those attacked by
it died of it. In 1832, I began to visit hospitals as a medical
student, and for eight years, at home or abroad, was almost a daily
attendant. The number of recoveries of those that I saw in that time
can be counted on the fingers of one hand. This may be regarded as its
natural mortality, for the treatment of that day seemed to exercise
little or no control over it. (Farther on this matter will be referred
to again.)
DURATION.--Chomel believed that the disease might prove fatal in
eighteen hours, while he regards its average duration as seven or eight
days. I very much doubt whether peritonitis, not caused by perforation,
violence, or surgical operation, was ever fatal in eighteen hours. I do
not remember any case of shorter duration than two or three days. Then,
on the other hand, the period of seven or eight days in the fatal cases
appears to me too long. In the early part of my professional life I
remember to have looked for death in three or four days. At present, in
the fatal cases, life is prolonged to double or more than double that
time. In the majority of those that recover at present the duration of
the symptoms is from two days to a week; in a few they have continued
fourteen days; and lately I have assisted in the treatment of a case in
which there was little amelioration for forty days, and yet the
peritonitis was cured.