diseases that are more easily recognized. It is when these symptoms are
slowly or irregularly manifested, or when some other disease which may
account for many of the symptoms occurs with it or precedes it, that
there {1144} should be any real difficulty. It is customary to regard
the danger of confounding the transit of a renal or hepatic calculus
with peritonitis as worthy of comment. But if the reader will turn to
the articles in this work which relate to these topics, he will find
the symptoms so widely different from those enumerated in this article
as belonging to peritonitis that he will be surprised that this item in
the diagnosis should have occupied so much room.
In a case already referred to, in which peritonitis followed gall-stone
pains, the transition was so marked by the rapid acceleration of the
pulse and swelling of the abdomen that each of the three physicians in
attendance at once appreciated the significance of the change. A
physician who resided in the country called on me to report his own
case. He had a little before had a very painful affection of the
abdomen which continued for three days. The pain was paroxysmal,
confined to the region of the liver, back and front, for one day; after
that there was some tenderness over most of the abdomen, but no
tympanitis. His pulse became frequent and his temperature advanced to
103°. His physicians believed that these symptoms justified them in
treating him for peritonitis. Yet his position in bed was constantly
changed, and no one attitude long continued--a restlessness which never
occurs in peritonitis, but is common in calculus transits. Add to this
the absence of gaseous distension and of the green vomit, the
paroxysmal character of the pain (though I remember one case in which
peritoneal pain increased and diminished somewhat regularly, but only
one), and, finally, the sudden cessation of the pain, such as often
happens in calculus transit when the calculus passes into the
intestine,--it is plain that his sufferings were caused by a
gall-stone. The elevation of temperature was the result of a
long-continued worry of the nervous system, and the abdominal
tenderness came from the many times repeated contraction of the
abdominal muscles which occurs in hepatic colic. And then, to make the
diagnosis more complete, this gentleman, after twelve or fourteen hours
of pain, became jaundiced--in the end very much so. There was no
absolute constipation, and the stools were of the color of clay from
the absence of bile.
The points of difference between renal colic and peritonitis are even
better defined and easier recognized than those between it and hepatic
colic.
In intestinal colic there may be some inflation of the bowels, and if
it continues a day or two there may be some tenderness; but it is for
the most part distinguished from peritonitis by the intermittent or
remittent character of the pain, by its greater severity while it
lasts, by its courting, rather than repulsing, pressure, by the
moderate acceleration of the pulse, by no or only slight elevation of
temperature (exception being made for long continuance), by the absence
of the green vomit, by the absence of the fixed position of
peritonitis, etc.
There does not seem to me any need of spending time to distinguish
gastritis or enteritis or neuralgia from peritonitis, their symptoms
are so wholly different; and if, as is said, the mucous inflammation
can penetrate all the coats of the stomach or intestine, and so cause
inflammation of the peritoneal layer, that is peritonitis, and will be
distinguished by the proper symptoms of peritonitis.
TREATMENT.--Chomel[4] says: "If general peritonitis is intense, it
{1145} should be attacked by the most powerful therapeutic agents. One
should immediately prescribe a large bleeding from the arm--from 500 to
600 grammes, for example--and repeat according to the need once or even
twice in the first twenty-four hours; apply to the abdomen, and
particularly to the part of it where the pain was first felt, leeches
in large number--fifty, even a hundred--as the violence of the disease
may demand and the strength of the patient will permit." He recommends
baths, presumably tepid, and describes an apparatus by which the
patient can be put into the bath and lifted out of it without pain;
prescribes a fixed posture, gentle laxatives, mercurial frictions,
blisters; conditionally and doubtfully, paracentesis, emetics under
certain circumstances--musk, etc. under others. In the treatment of
general peritonitis there is no reference to opium. The word does not
occur, but it does in the treatment of peritonitis following
perforation. In this condition he would, among other things, give opium
à haute dose, but he does not prescribe any repetition or give any
details. It is probable that the idea was obtained from Graves, whose
first use of opium in this accident was in 1821, although its first
publication appears to have been by Stokes in 1832.
[Footnote 4: _Dictionnaire de Médecine_, 1841.]
Wardell,[5] who has written the latest treatise on the disease we are
considering, relies greatly on bloodletting, but falls short of Chomel
in the quantity of blood he would take--would bleed, not to withdraw a
certain number of ounces, but to produce certain effects. The
venesection is to be followed by the application of leeches--twenty,
thirty, or forty--to the abdomen; after this turpentine applications to
the bowels. After depletion, he says, opium should be given at once:
"two or three grains may be given in urgent cases." Vesication he calls
"another of our aids." He disapproves of cathartics, but when there is
accumulation in the colon would use injections. "Opium in the asthenic
form is the chief agent, and Graves and Stokes were among the first
physicians who gave it very largely." "Two or three grains may at first
be prescribed, and a grain every four or three, or even two, hours
afterward." "In perforation there is sometimes great toleration of the
drug. Murchison has known so large a quantity as sixty grains to be
given in three days with impunity." Mercurials, he thinks, are of
doubtful efficacy. In the paragraph devoted to the treatment of
puerperal peritonitis the word opium does not occur, and it is only by
a very doubtful inference that we can assume that he would ever use it.
Chomel makes no allusion to the use of opium in the same disease.
[Footnote 5: _Reynolds's System of Medicine_.]
For two years (1834-36) I was connected with the New York Hospital as
house-physician or in positions by which that office is reached. The
treatment of acute diffuse peritonitis then and there was formulated as
follows: First, a full bleeding from the arm, commonly sixteen ounces,
then a dozen or more leeches to the abdomen; following this, another
bleeding or not, in the discretion of the physician. Meantime, the
patient would take half a grain to a grain of calomel every two hours,
with a little opium "to prevent the calomel acting on the bowels," of
which there was no danger, in truth. Mercurial inunction was used at
the same time. The belief was that after depletion the most important
thing was "to establish mercurial action in the system;" in other
words, {1146} "to diminish the plasticity of the blood." Under this
plan I saw one recovery in these two years.
In 1840, I went to Vermont to give a course of lectures in the Vermont
Medical College, and while there was called by the physicians to see
with them several cases of peritonitis. I found that they were treating
the disease on the Armstrong plan; that is, bleeding freely, and then
administering a full dose of opium, as they said, "to prolong the
effects of the bleeding." In most cases there was a second bleeding and
a second administration of opium. Leeches were also used, and
irritating applications to the abdomen, and in some cases purges. I
found they were getting better results than we were in New York, and I
studied their cases as closely as I could, and reached the conclusion
that opium was the curative agent, and that it would be safe to omit
the abstraction of blood. This conviction grew in strength with every
new case, and I saw, with different physicians, several cases, the
disease being more prevalent among the mountains there than in the
city--at least that year. The idea then formed was that to establish
the narcotic effects of opium within safe limits, and continue them by
repeated administration of the drug, would cure uncomplicated
peritonitis--that a kind of saturation of the system with opium would
be inconsistent with the progress of the inflammation, and would subdue
it. There was no theory to build the treatment on, and no explanation
of the action of the drug in my mind. What I saw of the action of two
full doses of opium was the only foundation for the idea. I had in the
course of two years after those observations in Vermont 9 cases of
general acute peritonitis, 8 of which were cured. All these were
reported in succession, as they occurred, to the medical societies and
in my college lectures. The plan was adopted by many members of these
societies and by others with whom I had opportunity of conversing on
the subject, so that soon there were several--I may say many--workers
in the field; and in all instances where the practitioner had the
courage to carry out the treatment favorable reports were returned. Not
that every case of peritonitis was cured, but the recoveries generally
exceeded those that followed any other plan ever before used. No
physician tried it with a proper understanding of its details, and with
courage to execute them, who if living does not practise it to-day.
The treatment of puerperal peritonitis is not allotted to me, and I am
very reluctent to encroach in any degree on the province of the very
competent and highly-esteemed gentleman to whom that disease was
assigned. But the history of the opium treatment is very incomplete
without the statement I am about to make, and I trust to his generosity
to forgive this encroachment; and all the more confidently because he
was not at the time acquainted with the manner in which opium was first
introduced into the treatment of puerperal fever.
After the curative action of the drug was demonstrated in general
peritonitis, I was anxious to try it in puerperal fever, of which
peritonitis forms a part. But I had no hospital and no obstetrical
practice. In 1847, I was appointed one of the physicians to Bellevue
Hospital, to which an obstetrical department was attached. After one or
two years a single case occurred and was sent to my division. I gave
her 100 grains of opium in four days, with more or less of calomel--I
have {1147} forgotten how much. She recovered, but after the symptoms
of puerperal fever passed away she had secondary abscesses of the
lungs. These kept her ill for several weeks. At length her recovery was
complete.
In 1840 there was a very fatal visitation of puerperal fever in this
hospital, and on invitation of Vaché, who then had charge of the whole
institution, I was a daily visitor and took notes of all the cases. It
was from these notes that Vaché compiled his report of the epidemic
published in the _Medical and Surgical Journal_. The disease was
fearfully fatal, although every known mode of treatment was tried in
different cases, including Brenan's plan by turpentine, but all, with
one or two exceptions, with the same result. At this time the opium
plan was on its trial, and I had not acquired a confidence in it that
authorized me to try it in these cases. The time for it came in 1851.
Then a sudden, vigorous attack occurred. One woman was sent to me in
whom the disease was well advanced. I instructed my house-physician not
how much opium to give, but what effects to produce by it. I found this
woman dying the next day, and that she had taken only three grains of
opium in three doses. In three or four days seven cases were sent me
from the lying-in wards. One was returned for error in diagnosis, and
six put under treatment. Having found that prudence in my
house-physician was so much more conspicuous than courage, another
house-officer, who combined them both, was selected to be in almost
constant attendance. The instruction I gave him was in these words: "I
want you to narcotize those women to within an inch of their lives." He
did it, and saved every one of them. This gentleman is now known over
the whole land as a learned and distinguished surgeon. I feel called
upon to give his name in this connection, that he may be a witness to
the facts I state, and for the admiration with which his nerve and
prudence impressed me. One of these patients took first two grains,
then three grains, then four, and so on till she took twelve grains of
opium at a dose, the intervals being two hours. The state into which
the patient was to be brought I have denominated a state of
semi-narcotism. The quantity of the drug necessary to produce this
state varied surprisingly in different persons. One of these women was
pretty fully narcotized by four grains every two hours. She was watched
with anxiety; restoratives were kept in readiness, but nothing was done
but to suspend the administration of the medicine and to wait. In seven
hours the consciousness was fully restored, and the improvement in her
condition was wonderful. The disease seemed to be cured. But in a few
hours more the symptoms recurred, and the same medicine was again given
in three-grain doses, and again narcotism was produced. Taught by the
experience of the day before, we waited, and when she recovered from
this second narcotism her disease was completely cured. She took no
more medicine of any sort. This case was very instructive, as it taught
me that over certain cases of puerperal fever opium has absolute
control.
From the time here referred to, so long as the obstetrical service was
maintained at Bellevue Hospital, a large proportion of cases of this
fever, as they occurred, were sent to my wards, and in all these years
I have not lost faith in opium. This statement, however, requires an
explanation. Puerperal fever is a compound disease. Its great
inflammatory lesions are found in the uterus and its appendages and in
the peritoneum. {1148} When the inflammation of the uterus is the
dominant lesion, and is purulent, opium has little or perhaps no
control over its fatality; but in the cases in which peritonitis is the
ruling lesion, if begun early, it will show its power. In this
connection I will only add that in private practice the drug has been
perhaps more curative than in the hospital. I have seen many cases in
consultation, and a decided majority have recovered. In some instances
the patient has fallen into a pleasant sleep, only broken by some
administration, and ending with her recovery. In one instance a very
eminent physician had undertaken to treat a case by the opium plan, but
he had administered the drug so timidly that for fourteen days he had
done no more than hold the disease in check. After trial, I found that
I could not induce him to give the drug in my way, and I asked him to
give me sole charge of the patient for twenty-four hours. To this he
assented, remarking, "If you cure her, doctor, I will have it announced
to the profession that she was the sickest person I ever saw get well."
In half the time allowed me I was able to establish the opium symptoms
as given farther on, and the lady slowly recovered.
The treatment of any form of peritonitis by opium permits the use of
the drug itself, or of any extract or preparation of it which contains
its narcotic qualities, but it is wise to persevere with that one first
chosen unless there is strong reason for a change. This caution is
based on the fact that we cannot change from one to another and be
certain to obtain the same drug activity. For example, we begin with
laudanum, and find what it will do. We cannot take in its place the
sulphate of morphia with the certainty that we can so graduate it as to
get precisely the same effects. Then the quantity which will be
effectual in one case may be quite inadequate for the next. The
tolerance of opium in different persons varies remarkably, and probably
the disease itself increases the tolerance in all. This will be
illustrated by some of the details of this paper.
The drug symptoms to be produced are as follows: Subsidence or marked
diminution of the pain; some or considerable tendency to sleep;
contraction of the pupils; reduction of the breathing to twelve
respirations in the minute; in the favorable cases a considerable
reduction in the frequency of the pulse; a gentle perspiration; an
itchy state of skin, or oftener of the nose; absolute inactivity of the
bowels, and after a time a subsidence of the tumor and tenderness in
them; some suffusion of the eyes.
Of these several signs of opiumism there is none more easily observed
and none more valuable than the frequency of the respiration; and while
the physician aims to reduce it to twelve in a minute, there are
chances that he will see it fall to something below that. I have often
counted it at seven, and in perhaps two cases it fell to seven in two
minutes; and yet these cases of marked oppression from opium all
recovered. In the cases in which the respiration has fallen so low
there has been considerable obtuseness of the mind; but in no case
except in the hospital patient already referred to have I seen
unconsciousness. Then the sleepiness, so long as the patient is easily
awakened, is wholly within the limits of safety.
As to the quantity of opium to be given, I have known two grains every
two hours do the work, and in other cases many times this {1149}
quantity was necessary to produce this condition of semi-narcotism. The
plan is to begin with a dose that is safe--say two or three grains of
opium or its equivalent of sulphate of morphia--and in two hours notice
its effects. If any of the opium symptoms have appeared, repeat the
dose; if none, increase by one grain, and so on at intervals of two
hours till the degree of tolerance in the patient is ascertained. After
that the case can be treated by a diminished occupation of the
physician's time--two or three visits a day. The dose is to be
increased if the opium symptoms diminish before the disease yields, but
always to be diminished or discontinued if narcotism is approaching.
The duration of the treatment will be sometimes no more than two or
three days; it may be a week, or even a fortnight, and in one case
already mentioned the symptoms persisted mildly for forty days, and
then yielded. In this case the medicine used was the sulphate of
morphia, and the enormous dose reached by steady and graduated increase
was one grain and a quarter every forty minutes in a boy ten years old.
In some puerperal cases the doses have been so large as to require
witnesses to make the statement of them credible, and the
administration of them criminal had not the effect of each dose been
carefully studied and the amount of each measured by the action or
inadequate action of the next preceding one.
Here are the doses given a woman who fell sick October 13, 1857; the
record was made by C. H. Rawson during the treatment, and was kindly
given me two or three years ago: On the first appearance of her
disease, while the diagnosis was uncertain, 10 grains of Dover's powder
gave her a quiet night. The next day the disease was more manifest, and
she took of Magendie's solution (2 grains of sulphate of morphine to a
drachm of water) x minims every hour; growing worse, at night she took
xxx minims every hour; the next day, xl minims every hour, and no
change of symptoms. She took in twenty-four hours 32 grains of sulphate
of morphia; slept, but was awakened by the slightest noise. On the
fourth day 3-1/3 drachms of the solution, and opium as follows: at 4
P.M., 3 gr.; at 5 P.M., 4 gr.; at 6 P.M., 5 gr.; at 7 P.M., 6 gr., and
6 gr. hourly after 7 P.M. Sleep light. Fifth day, in twenty-six hours
took in opium and morphine the equivalent of 208 gr. of opium. The
sixth day, 212 gr. of opium; on the seventh day, 221 gr. of opium; on
the eighth, 224 gr.; on the ninth, the same quantity; on the tenth, the
same; on the eleventh, 247 gr., pulse subsiding; on the twelfth, 261
gr., other symptoms better; on the thirteenth, 144 gr.; fourteenth day,
4 gr. hourly; slept for the first time heavily, all other symptoms
improving, bowels moved freely, ate well, tympanites subsiding;
fifteenth day, 1 gr. of opium every two hours, and at night the last
dose. Recovery was complete. The woman denied the opium habit, and the
medicines were tested by the apothecary. Such doses can only find their
justification in the demonstrated fact that smaller doses will not
produce the degree of narcotism desired.
In Keating's edition of Ramsbotham's _Midwifery_ a case is reported by
myself in which a woman, by pretty rapidly increasing doses, reached
forty-eight grain doses of opium, with the effect of curing her disease
and substituting a temporary active delirium.
A word of caution is probably necessary regarding the use of opium in
high doses when peritonitis and Bright's disease coexist. I have {1150}
already said that I have but scanty personal knowledge of such a
concurrence, but in Bright's disease alone I have known a large,
non-heroic dose of an opiate fatal. For example: A young man had a
felon on his finger, and did not sleep, so great was his pain. His
physician prescribed 40 drops of laudanum at bedtime. Not sleeping on
this, he took another portion of 40 drops, and in the morning he was
found in a comatose condition, and in the course of the day he died. A
post-mortem examination revealed Bright's disease, which was not before
suspected. A woman took half a grain of the sulphate of morphine--for
what reason I do not know. I was called to see her when she was in a
semi-comatose state. The time between my seeing her and that of taking
the morphine was fourteen or fifteen hours; its removal from the body
was therefore hopeless. Her limbs were swollen with oedema, and the
urine contained albumen and casts. Although the usual means of opposing
the poisonous effects of opium were resorted to, they were of little
use, and the patient died in the course of the day. These are selected
from a considerable number of similar cases that show a similarity in
their action on the brain of opium and urea. It seems that opium
precipitates the uræmic coma, yet the coma produced by these agents
combined is not so profound as that produced by opium alone. There is
in it some movement of the limbs or body or some imperfect utterances,
yet it seems to be more fatal than the coma of opium unaided.
Notwithstanding all this, I have met with several cases of cardiac
disease combined with Bright's--perhaps I should say many--in which
half a grain of morphia sulphate has been taken every night to procure
sleep with only beneficial results. This has been observed several
times when physicians have been the patients.