control the administration of opium when there is urea in the blood,
whether there is peritonitis or not; but a case in which one form of
Bright's disease preceded, and perhaps caused, peritonitis will be more
instructive: A gentleman sixty-eight years of age was attacked by
peritonitis on Thursday evening. There was a moderate chill at the
onset (this being one of the few cases in which I have witnessed this
occurrence). The diagnosis was then uncertain, and he took quieting
doses of Dover's powder, which gave him sleep. The next day the
diagnosis was easily made. The urine was examined for albumen, and none
found. It was, however, scanty. He took only six-eighths of a grain of
sulphate of morphine in the first twenty hours. It was then increased,
so that in the next twenty-four hours he took two grains of the
sulphate in divided doses--a quantity which has been greatly exceeded
in hundreds of cases with the best results; but in this case coma was
the result. At 10 A.M. on Sunday he was comatose, but not profoundly;
he could be aroused. The breaths were five in the minute, the pulse
increasing in frequency; secretion of urine next to none. The galvanic
battery was used. After seven hours, while the respiration was growing
more natural, the pulse grew more frequent and the stupor increased. At
8.30 P.M. the breathing was fifteen in the minute, and full and
perfectly easy, but the pulse was running at 140, and the coma
unbroken, and the pupils of good size. The effects of the opiate had
passed off, but those of uræmia were profound. He died at 11 P.M. After
the alarming symptoms occurred we tried to procure another specimen of
the urine for fuller examination, but {1151} could not. It was only
after his death that we procured the evidences that he had shown
symptoms of contracted kidney for months. The urine contained no
albumen at the time of our examination, as very often happens in that
disease.
Regarding other points in the opium treatment there is little to be
said. Purgatives are entirely inadmissible. The bowels should be left
entirely at rest till they recover their muscular tone; then they will
expel first the gas, and then the feces; or if, after the inflammation
is subdued, they do not move of their own accord, injections are
admissible. I have often left the bowels absolutely inactive for
fourteen days without any recognizable consequences. If I meet a
physician who believes that leeches are essential, I yield him his
point, but never advise them. I do this because a moderate bloodletting
will do no harm, and little if any good. The same rule I apply to
irritating applications to the surface of the abdomen. Mercurials, I
think, are harmful, and therefore I object to them. As to food, it
should be milk, fresh eggs beaten up with water and pleasantly
flavored, peptones, etc. selected from among those that leave no
refuse.
The testimony of physicians who have adopted this plan within my own
circle is unanimously in favor of it. B. R. Palmer of Woodstock, Vt.,
afterward of Louisville, Ky., who was the first to test it, told me
after a few years' trial that he used to dread peritonitis as he would
dread the plague, but with opium in his pocket he met it cheerfully and
hopefully, as he did a pneumonia. Chalmers of New York, who is known by
many readers of this article, has a very extensive practice, and he
told me lately that he had not had a fatal case of peritonitis in
twenty-two years. He embraced the plan early.
Now, how did this treatment originate? From whom did the profession
adopt it? In 1836-37, I visited daily the hospitals of London,
Edinburgh, and Paris, was in frequent intercourse with the physicians
of those cities, and never saw a patient anywhere treated by opium, and
never heard the least allusion to it. I can safely appeal to any
physician who was familiar with the history of the profession before
the year 1840, or for two or three years later perhaps, to inquire
whether anything was generally known regarding this treatment of
peritonitis, or whether he himself ever heard of it. Let the inquiry be
made of Willard Parker of New York or Alfred Stillé of
Philadelphia--men of a degree of intelligence and learning that has
made them leaders in the profession--and of all the profession at that
time. I venture to assume that they were as ignorant as I was of what
Graves and Stokes had done.
The following fact is significant: In 1843, Graves published _A System
of Clinical Medicine_, the preface of which is dated January, 1843. In
this he says he had previously published essays, lectures, and articles
in several medical journals. In this volume he intends, he says, "to
revise what I have written, and to compress the whole within the limits
of a single volume." There is nothing in the table of contents or
explanatory headings of the several chapters of this volume which
alludes to treating peritonitis by opium. It is fair to infer that the
cases treated in 1823 had made little impression on his mind, and that
he did not think his treatment could take rank as a discovery; and yet
Stokes had made favorable mention of it eleven years before this
publication. Graves, then, did not {1152} publish his cases, and the
first knowledge which the profession could have of them was through
Stokes's paper, published in the _Dublin Journal of Medical and
Chemical Science_, No. 1, in 1832. Perhaps the reason why Stokes's
paper produced so little impression on the profession may be found in
the fact that first numbers of journals of every sort have few readers.
Anyway, it was not till after the opium treatment had attracted much
attention in this country that anybody here knew that Graves or Stokes
had ever had anything to do with it. Besides, Graves and Stokes had
only used opium in cases of perforation, and they had no plan or
symptomatic guide in the use of the drug.
There is something new and strange in the following case copied from
the _Medical Record_ of May 12, 1883, under the heading, "Operative
Measures in Acute Peritonitis:" "Dr. Reibel relates the case of a
child, eight years old, suffering from acute idiopathic peritonitis.
The disease had resisted all treatment, and the child being,
apparently, about to die, it was determined to open the abdomen with a
view to removing the fluid and washing out the peritoneal cavity with a
solution of carbolic acid. The meteorism was intense. No fluid was
found in the abdominal cavity. In prolonging the incision a loop of the
intestine was punctured, as evidenced by the escape of gas and
intestinal fluid. The wound was washed with carbolic acid and covered
with a layer of antiseptic cotton. The following day the little patient
was nearly free from pain, and was able to retain a little milk. The
temperature had fallen from 104° to 101°, and the tympanitis was almost
entirely gone. The (wounded) loop of intestine was adherent to the
abdominal wall, and there had been no escape of fluid into the
peritoneal cavity. The patient made an excellent recovery."
If the statements of this abstract are true, and the future supports
the practice pursued in this case, acute peritonitis is likely to
become a surgical rather than a medical disease. Reibel thinks that
opening the intestine in the way he did is a better plan than the
punctures with the exploring-needle to relieve the patient of the
tympanitis. But it will require more facts than one to persuade the
profession that this mishap of the scalpel can grow into a rule of
practice. (The _Record_ finds this report in the _Journal de Médecine
de Paris_.)
I cannot say that I see the value of a distinction made in 1877 by
Gubler between peritonitis and peritonism. By the latter term is meant
the total of nervous and other symptoms that arise in the course of
peritonitis. Trasour has lately revived this distinction, and thinks it
important, and that a light peritonitis may be attended by a grave
peritonism. He holds that the distinction is important, because "the
treatment of peritonism consists in the administration of alcohol,
chloral, and especially of opium in large doses. Of the latter fifteen
grains may be given in twenty-four hours." "The symptoms [of
peritonism] are produced through the agency of the great
sympathetic."[6]
[Footnote 6: _Med. Record_, Aug. 28, 1883.]
I cannot say that I have seen great effects follow small causes, but
think that, in general, the effects of peritonitis on the pulse,
strength, nervous tone, etc. are, to some extent at least, a measure of
its severity.
CONSEQUENCES OF PERITONITIS.--These are usually nothing. When recovery
takes place it is commonly complete, but cases have been known {1153}
in which the intestines have been left bound to the abdominal wall and
to each other, and so made incapable of their natural action. The
results of this are a swollen, tympanitic abdomen and impaction of the
bowels, but the general health may be very good. A woman at Bellevue
was left in this condition, yet she performed the duties of nurse in
one of the wards for some years, and finally disappeared from the
institution, and I do not know how it ended with her--probably by the
breaking up of the adhesions and a return of the bowels to their
natural condition.
In some few cases there remains new tissue, which in time is partly
broken up and remains partly attached. In this manner strings and bands
of considerable strength can be formed, and into these loops the
intestine may pass, so as to form an internal hernia of a very
dangerous character. In some bands are formed across the intestine,
which by contraction flatten the tube and obstruct the fecal movement.
There is reason to believe that such bands and bridles are formed by
local inflammation of such imperfect manifestation by symptoms that the
patient knows nothing about it. A very striking case illustrating the
possible sequence of this inflammation came under my observation early
in my professional life: A colored woman about twenty-five years of age
gave a very clear history of a peritonitis from the consequences of
which she had suffered two years before I saw her. About six months
after recovery she began to have constipation and to suffer from small
and frequent discharges of urine. The latter gradually grew milky and
to have a bad odor; the constipation grew more and more, and at length
came to be absolute for many days; then would come a diarrhoea of some
hours' continuance, after which she would have a feeling of relief.
This was her state when I saw her. She was emaciated, and so feeble as
hardly able to leave her bed. She vomited occasionally, and her
appetite for food was all gone. The urine was heavily loaded with pus,
and was ammoniacal. She died after a few weeks. At post-mortem
examination a firm membrane was found strained across the upper strait
of the pelvis, wholly separating the abdominal cavity from the pelvic.
It looked like a drum-head. The left posterior border was drawn very
tensely over the colon where it passed into the pelvic cavity,
flattening it down completely and making stricture. To the under or
lower surface the fundus of the uterus and the base of the bladder were
firmly adherent, and in this way both were suspended. The effect of
this unnatural suspension of the inactive uterus did not seem to be
noticeable, but with the bladder it was very different: it contained
three to four ounces of water, ammoniacal and full of pus, and it could
never have emptied itself. The explanation is very simple. During the
peritonitis a false membrane was effused on the pelvic viscera in situ.
When the period of contraction which is common to all such structures
came, the new membrane was separated from the greater part of these two
organs, but not from their bases. The firm attachment to the brim of
the pelvis did the rest. So unusual a sequel of peritonitis I think
deserves a record. I should add there were no adhesions above the
pelvis. Such a structure as this, found long after the active symptoms
of peritonitis have passed, as also the bands and cords before spoken
of, does not give support to the doctrine that the false membranes are
broken down into fatty matter, and in this condition absorbed.
{1154} The possible remote effects of peritonitis are shown in a case
reported by E. A. Mearns to the _Medical Record_, published Sept. 15,
1883: A young man, aged nineteen, four years after he had had acute
general peritonitis was attacked with constipation, which was absolute.
He had had before occasional attacks of pain in the bowels and
constipation, which were overcome. But this was invincible. He had the
train of symptoms usual in intestinal obstruction. There was no fever
or tympanitis, and this time but little pain. He lived eight days.
There was a tangle and a constriction of the intestines at the middle
of the ileum, caused by the contraction and hardening of the effusion
of the old peritonitis, and the intestine was very much softened.
H. B. Sands reports in another number of the same journal: "The patient
was a man about thirty who had suffered from acute obstruction for a
week. No exact diagnosis was made. When the abdomen was opened the
intestinal coils were found extremely adherent one to another in
consequence of a former peritonitis. A careful search failed to
discover the nature or seat of the obstruction. The abdominal wound was
closed, and the patient died soon after."
Peritonitis from Perforation.
There is no part of the gastro-intestinal canal that may not, from one
cause or another, become the seat of ulceration. The jejunum is the
part of the tube long supposed to be an exception to this rule, but
even in it one or two observers have found ulcers. These ulcers often
exist without distinctive symptoms, and may go on to cicatrization
without announcing themselves. In the stomach, however, there are
commonly indications which will admit a conjecture of their existence,
and perhaps a diagnosis. Sometimes these ulcers penetrate all the
tissues of the tube and allow the contents of the intestine to escape
into the peritoneal cavity, or they may have destroyed all but the
external layer, and some succussion, as in coughing, sneezing,
laughing, or perhaps straining at stool, may make the opening complete,
with the same results. In these cases it seems to be inevitable that
inflammation should follow, unless it has preceded, the complete
opening and sealed it up by adhesions. The tendency of such an
inflammation is to be local and limited, but when the contents of
intestines escape into the peritoneal cavity it usually becomes
general. These accidents are usually attended by the sudden development
of local pain, by rapid increase in the frequency of the pulse,
paleness, and prostration. The perforation of the vermiform appendix is
often a partial exception to this statement, for, while the local
symptoms are marked, the sympathy of the general system is not so
quickly awakened. The same can be said of perityphlitis. The symptoms
are often local for some time--a day or more; sometimes subside, as if
the disease were cured, and then return in full form. This is produced
by the tendency of the inflammation to limit itself to the immediate
neighborhood of its cause. Lymph is effused at a short distance from
the point of irritation, and seals the parts together, so as to shut in
the offending substance; and though this substance may produce pus in
contact with intestine or appendix, that {1155} fluid is held for a
time, as in abscess. It may be permanently held in its new-made sac
till it burrows into some near part, as the intestine or bladder, or
remain an abscess till opened by Willard Parker's puncture. On the
other hand, the contents of this sac may be increased till it breaks
bounds and causes extension of the peritoneal inflammation or general
peritonitis. In one particular case this process of setting limits and
breaking through them occurred in a young lady four times at intervals
of from one to two days. When the limiting adhesions were established
symptoms would subside, so as to encourage in her physicians the hope,
even the expectation, of recovery; but again and again the fire was
rekindled, and she died eight days after the first attack. In the
greater number of cases the first breaking of the adhesions is followed
by full peritonitis, and this often by death.
The perforations of the stomach which I have seen have not been
attended by the severe pain described by most authors, but by a sudden
prostration of strength and a feeling of disquiet and sinking at the
stomach; more of collapse than of inflammation in the symptoms; no
tumefaction of the bowels; almost nothing to indicate the nature of the
accident, but a sudden new sensation in the bowels, a rapid increase in
the frequency of the pulse, it growing small as it increases in
rapidity, and a pale and shrunken countenance, and death in from twelve
to thirty hours. Then, on inspection, hardly any signs of peritonitis
are found. The peritoneal vessels are fuller and the membrane redder
than in health, and its surface covered with the thinnest possible film
of lymphy exudation, and some serum in the deeper parts of the cavity.
These ulcerations of the stomach are not always fatal by peritonitis. A
few instances are recorded in which adhesions of the outer surface of
the organ to adjoining organs have taken place, so as to protect the
peritoneum almost wholly from the fatal contact with the gastric
fluids, and death has occurred in some other way. I have a remarkable
specimen illustrating this fact. It was taken from the body of a woman
of about middle age who had long had symptoms of dyspepsia, and had
from time to time vomited a little blood. It was not difficult to
recognize ulcer, but the extent and peculiarities of it could be
learned only by inspection. She died suddenly of copious hæmatemesis.
On examination an ulcer two and a half to three inches in its several
diameters was found, beginning near the pylorus and extending toward
the left, which in this large space had destroyed all the coats of the
stomach and exposed an inch and more of the right extremity of the
pancreas and about the same extent of the liver. The liver and pancreas
were both perceptibly eroded when exposed, and in the latter an artery
that would admit the head of a large pin was opened. The stomach,
outside of this extraordinary ulcer, was strongly attached to the
adjacent organs.
The ulcerations of typhoid fever penetrate the intestine about three
times in a hundred cases of the fever. This result is reached by the
study of a large number of cases, and appears to be pretty generally
admitted. The point where this perforation occurs is in the ileum, near
the ileo-cæcal valve--within a foot or eighteen inches of it in the
great majority of cases, although it has been known to occur
seventy-two inches above the valve, and it has been seen very rarely in
the cæcum. The fever itself may be either severe or mild. Suddenly
severe pain {1156} sets in, oftenest in the lower part of the abdomen,
and spreads rapidly; the pulse is quickly accelerated and becomes
small; and it has been lately stated that in this and other intestinal
perforations the gases of the bowels, escaping into the peritoneal
cavity, will give resonance to percussion over the lower part of the
liver. Fetid gas found in this cavity after death is not without
importance; for example, a distinguished Senator at Washington died not
long ago of a very painful abdominal disease which his physicians
declined to relieve with opium, though the patient pleaded for it. His
family physician at home was summoned. Although the distance he had to
travel was many hundred miles, he found the patient alive and still
suffering. He at once gave morphine for the relief of the pain, but the
patient died. Now, this gentleman had diabetes a year or more before
his death, recognized by his physician at home and also by myself.
While under my observation the urine ceased to contain sugar and its
quantity became normal, but soon after this albumen was occasionally
found in it. The quantity was generally small, and casts were only
found now and then. This new disease was mild, and seemed to be, within
certain limits, manageable. He went to Washington under injunction that
he was not to let official and professional labors bear with any weight
upon him. This last sickness and the death would naturally enough be
supposed to be some new phase or consequence of the previous illness.
But, while a post-mortem examination was not permitted, the family
wished to have the body embalmed. The family physician accompanied the
embalmer, and as the latter made a cut through the abdominal walls
there was a gush of air laden with fecal odor, and he through this
opening saw the intestines covered with false membrane. He satisfied
himself that the intestine was not opened. This fetid gas came from the
peritoneal cavity. An ulcer had perforated the intestine somewhere, and
caused the death. The final disease could be only remotely dependent on
the patient's previous illness, if at all. His impaired health may have
made the ulcer possible.
All kinds of perforations in the bowels, except those of the stomach,
cæcum, and appendix, even the cancerous, have one history and the same
symptoms; and if treatment is ever successful in such occurrences it
must all be based on one set of rules--absolute rest, no pressure on
the bowels, and no movements of the muscles that will aggravate it;
food that will be wholly digested and absorbed by the stomach; complete
abstinence from cathartic and laxative medicines, and the free
administration of opium or morphine. By these means, I fully believe,
numbers have already been saved from the fatal consequences of
peritonitis caused by perityphlitis and perforation of the vermiform
appendix--some under my own observation and others under that of my
friends. A boy fourteen years of age was brought to bed by a pain in
the right iliac fossa. After a few hours his father, a physician,
desired me to see him. There was already a perceptible fulness, with
dulness on percussion, in the fossa, and some febrile excitement. I
gave a portion of morphine, and promised to call the next morning. In
the morning a message came from the father stating that the boy was
better and there was no need of further attendance. In the evening I
was recalled. The pain had returned, and had spread over most of the
bowels. He had general peritonitis. He took tincture of opium, of which
I believe the largest dose was 100 {1157} drops, reached after three or
four days of gradual but steady increase of dose. From that point the
patient got better, and the quantity of the medicine was
correspondingly reduced. There were a relapse and a repetition of the
treatment, and again the disease yielded. During convalescence, about
fourteen days from the attack, the boy, after emptying his bladder, was
suddenly pressed to continue the discharge. Now he voided what appeared
to be blood, two or three tablespoonfuls. It was, however, pus with
blood enough to color it. This purulent discharge from the bladder
continued for about three weeks, the boy steadily recovering his
health. This occurred twenty or more years ago, and that boy is now a
well-known physician. Similar cases could be recited.
In 1850, or thereabout, I attended a physician through an attack of
typhoid fever. In the third week there was a sudden outbreak of
peritonitis. The opium treatment was resorted to, and he recovered, and
had good health for twenty years after. Peritonitis occurs rarely in
typhoid fever from any other cause than perforation, and its occurrence
in this case at this time, when perforation is more likely to occur,
renders it probable, at least, that this attack was produced by that
cause.
March 3, 1883, autopsy of Wm. Fletcher, age 59, iron-worker. On Friday
last, Feb. 23d, he was attacked with pain in the region of the right
iliac fossa; it was severe. There was no chill, but little fever, and
only slight acceleration of the pulse. His stomach was a good deal
disturbed, and the bowels were soon distended with flatus. I saw him on
the Tuesday following, with James D. Elliott. The bowels were a good
deal swollen and very resonant on percussion; pulse 84. His stomach was
still greatly disturbed, so that he retained no food, yet there was no
green vomit, but much flatulency. The movements in respiration were
particularly noticeable, being nearly or quite as much abdominal as in
health. There was a short friction sound in inspiration, but an entire
absence of the sound produced by peristaltic action. There was no
dulness on percussing over the iliac fossa, and no pain on pressure
over any part of the abdomen. I was careful in examining the right
fossa, for the first pain was there, and it was severe; but there was
no physical sign by which the perforation could be ascertained. Still,
my mind dwelt on the probability of perforation, and I expressed my
fears to Elliott regarding it. The respiration was of natural
frequency. The bowels had not moved for two or three days.