its progress. The only things uniformly attending it are tubercles on
the peritoneum and more or less of inflammatory effusion, chiefly lymph
and serum; tumor and hardness of the bowels, general or local; deranged
function of the stomach and intestines; emaciation; and extreme
fatality.
In some cases the invasion is acute and marked--a chill followed by
fever, vomiting, early development of meteorism, and in a few days a
point or points of resistance to pressure, but not necessarily dulness
on percussion. In a few days the febrile action and the meteorism may
subside, leaving the symptoms of local peritonitis. But we have not
long to wait for a renewal of them and an evident extension of the
inflammatory action. Remission and relapse alternate at varying
intervals, until the whole extent of the peritoneal surface seems to be
involved in inflammation. With this mode of development meteorism may
not be renewed in the most common way. The lymphy product of
inflammation may so bind the intestines to the posterior walls of the
abdomen that they cannot extend forward, but are pushed upward against
the liver and diaphragm, and so encroach on the thoracic space. But
then the anterior parietes are tense and hard, and do not move in
respiration. The febrile heat may not continue more than two or three
months, but the pulse will be frequent to the end. There will be a
thinning of bowel walls, and here and there a knuckle of adherent
intestines may cause some prominence and give some resonance on
percussion. There will be also occasional vomiting, and the dejections
will be irregular--maybe only deficient or thin; there may be an
alternation of constipation and diarrhoea.
Tuberculous ulcerations of the mucous layer of the bowels is not
uncommon in tubercular peritonitis, and these ulcers have in rare cases
perforated and allowed the fecal matter to accumulate in considerable
quantity in a sac limited by previous adhesions. In all forms of
tubercular peritonitis death is caused as often by grave complications
as by what appears to be the primary disease. The affection occurs in
probably every instance in those who had at the beginning, or had
acquired in its progress, what we call the tubercular diathesis. We are
not surprised, therefore, to find on inspection a wide diffusion of
tubercles in the body, particularly on other serous membranes, and in
the lungs. Death may occur, then, from phthisis pulmonalis or from
pleurisy or meningitis, as well as from the exhaustion and accidents of
the peritoneal disease. The effusion serum or turbid serum is very
common in tubercular peritonitis, and can be recognized by the dulness
it produces in part of the cavity, and sometimes by fluctuation. It is
often sacculated, but it is not constantly found after death, it having
been absorbed before, and perhaps long before, that event.
In other cases the invasion of the disease is stealthy and deceiving.
It comes so quietly that the patient is not conscious of any local
disorder beyond a dyspepsia and irregular action of the bowels. He has
a pulse of growing frequency, but if he knows it he ascribes it to his
dyspepsia. He is slowly losing flesh and strength; this he accounts for
in the same way. At length a perceptible swelling of the bowels
attracts his attention. At this stage the physician finds that the
swollen bowels are tympanitic everywhere or only in the upper, while
there is evidence of fluid {1166} effusion in the more depending,
parts. He discovers some, it may be little, tenderness on pressure, and
a pulse of 85, or maybe 90, increasing in frequency toward evening. The
appetite is poor, the digestion slow, and occasionally there is
vomiting; the complexion is pale and a little dingy; the skin of the
abdomen may be dry and rough or may be natural; some colicky pains have
been or soon will be felt. From this point the disease gradually
advances. The distension of the bowels slowly increases or they are
firmly retracted; the emaciation increases; the strength diminishes;
there is often cough, which is generally dry; the bowels are slow or
diarrhoea alternates with constipation; with the distended bowels there
is always more than natural resonance on percussion, except when there
is fluid effusion, though not often the full tympanitic sound observed
in acute diffuse peritonitis. This resonance is not equal, always, in
different parts of the abdomen; the respiration is embarrassed and
almost wholly thoracic. The abdomen is often as large as that of a
female at full term of pregnancy, and indeed the condition has been
mistaken for pregnancy. This is an inexcusable blunder in a case like
that which I have in mind--a young unmarried woman. She had no dulness
on percussion in the space that would be occupied by the gravid uterus,
but rather resonance. The case might have been a little less clear if
there had been fluid effusion in the abdominal cavity, but if this were
not encysted it would flow from one side of the abdomen to the other
when the patient turned correspondingly in bed; if it was encysted,
there would be small chances that it would have the shape and position
of the gravid uterus; if it had, there would be no chance of hearing in
it the foetal heart or feeling the foetal movements; and after all this
there remains the experimentum crucis--a vaginal examination.
At first the diagnosis is unavoidably uncertain. Some aid is found,
possibly, in the medical history of the family, in tuberculous
antecedents, yet I remember cases in which no phthisis could be found
in any living or dead member of the family on the paternal or maternal
side as far back as it could be traced. Some aid is found if the
patient himself has any of the physical or rational indications of
pulmonary phthisis, and yet there are recorded cases in which the
abdominal symptoms were the first to appear. The prominent German
physicians attach great importance to the pre-existence of a cheesy
mass or degeneration somewhere in the body as the real parent of
tubercles wherever they appear. The truth of this doctrine, I do not
think, has received anything like universal recognition; and if it had,
as this cheesy degeneration is often, perhaps commonly, only
discoverable after death, it could rarely give any assistance in
diagnosis, so that the early diagnosis is always difficult, and a very
early one often impossible. But as time goes on, and the symptoms are
better defined and show themselves one after another as they are above
described, it seems as if a careful observer could not confound it with
anything except perhaps one of the other forms of chronic peritonitis
or cancerous peritonitis. As to the latter, the cough which exists in
most cases of tubercular peritonitis will assist in the distinction,
but a physical examination much more; for a cough does not always
attend phthisis when this disease exists; for example, I visited a
daughter of one of the distinguished gentlemen of Vermont. She had had
the bowel symptoms that indicated tubercular peritonitis for eight or
ten months, and the diagnosis was not {1167} difficult. Remembering
Louis's opinion that if tubercles invade any other part of the body,
they are likely to be found at the same time in the lungs and in a more
advanced condition, I examined the lungs, and found in the upper part
of the right a cavity so large that it could have received a fist. I
was only surprised by the fact that she did not cough, and had not
coughed. She herself assured me of that (she was twenty-one years old);
her physician, who was present at the visit, had never heard her cough,
and had no suspicion of any pulmonary complication; but, more than all,
her mother, who had walked with her, slept with her, eaten with her,
travelled with her, and from the beginning of the illness had not been
out of her company more than twenty minutes in any twenty-four hours
since the disease began, had never heard her cough. Here, then, the
nervous deviation to the abdomen, or whatever else it may have been,
had so benumbed the sensibility of the pulmonary nerves that the
alarm-bell of phthisis had never been sounded; but the cavity, had
there been any doubt whether the bowel disease was cancerous or
tuberculous, would have almost fully settled the question. But more of
the peculiarities of cancerous peritonitis a little farther on.
The lesions of this disease (or its pathological anatomy) differ
considerably, but the differences are in the amount of tuberculous
deposit and the secondary results, not in the real nature of the
disease. Lebert has published among his plates of pathological anatomy
one which shows the peritoneum thickly sprinkled over with small
tuberculous grains, and represents each particular grain surrounded by
a little zone of inflammatory injection. There is yet no exudation, but
that would soon follow. A fibrinous exudation will soon come over this
primary deposit, and undergo a kind of organization, or at least get
blood-vessels, which in their turn can furnish the material for a new
crop of tubercles. These again provoke a new layer of fibrous tissue,
which also becomes studded with tubercles, and so on, till a thick
covering is formed over the intestines. But the same material is
interposed between their folds, separating one from another and
compressing them and diminishing their calibre; at the same time this
agglomerated mass is firmly adherent to the abdominal walls everywhere.
The new material may have a thickness of half an inch or even more. I
remember how surprised and confused I was when I made my first
inspection of such a case. The abdominal walls were cut through, but
they could not be lifted from the intestines, but were firmly adherent
to something. They were carefully dissected off and the bowel cavity
(?) exposed; there was apparently an immense tumor filling the whole
space: no intestines, no viscera, could be seen. A section was made
through this mass from above downward, and another parallel with it and
an inch distant from it, and this part removed. It appeared like a
large, hard tumor, through which the intestine made several
perforations. The new material appeared to be fibrous, with
grayish-white tubercles sprinkled in through it everywhere, and pretty
abundantly. In another case this fibro-tubercular material may occupy
one part of the abdomen, and a large serous cyst or serous cysts
another. The tuberculo-fibrous material may be found in markedly less
quantity than is so far described, till there will be no more than in a
case from Ziemssen's clinique, quoted by Bauer: "In the peritoneal
cavity about four liters of yellowish-brown, slightly turbid fluid.
Omentum {1168} thickened, stretched, adherent to the anterior wall of
the abdomen and beset with hemorrhages; the same was true of the
parietal peritoneum; between the hemorrhages whitish-yellow and
entirely white tubercles occur, varying in size from the head of a pin
to a lentil. The intestinal serous membrane was similarly invaded. The
intestines intensely inflated; a number of ulcers on the mucous
membrane, one approaching perforation. Covering of the liver thickened
by fibrinous deposition."
The lungs and serous membranes generally will, in all probability, show
more or less of tubercular deposit, the pericardium less frequently
than the others.
The result in this affection, after it is fully established, is
believed to be uniformly fatal, and at its commencement the difficulty
of diagnosis may lead one to doubt whether his apparent success is
anything better than apparent. Still, a plan which I have relied on is,
I believe, worth announcing. As soon as the disease is recognized the
patient is put upon the use of the iodide of potassium and the iodide
of iron, in full average doses, and a solution of iodine in olive oil
is applied to the whole surface of the abdomen by such gentle friction
as will produce no pain; and after a minute or two of such friction the
oil is brushed thinly over the surface and the whole covered with oiled
silk. This dressing is repeated twice a day. The quantity of iodine to
an ounce of oil will vary considerably in different persons; for some,
seven to ten grains will be enough; for others, thirty will be needed.
The iron is to make the application moderately irritating, and if it
produce pinhead blisters or blisters a little larger, all the better.
When the application becomes painful the oil is washed off, and the
application is not renewed for two or three days. In this manner it may
be continued for two or three months. Meantime, the patient is put upon
the diet and regimen of the consumptive, the appetite encouraged; he
takes sustaining food, with plenty of milk and cream, or cod-liver oil,
as much fresh air as possible, and friction is applied to other parts
of the body with dry flannel.
Cancerous Peritonitis.
Benign tumors of the abdomen are not frequently the cause of general
peritonitis, and when they are, the grade of the disease is acute
rather than chronic. They very often provoke local inflammation and
become adherent to the neighboring structures. The same is true of
malignant growths in the abdominal cavity, except that the adhesions
are earlier formed and more likely to occur. Localized cancer, of
whatever variety, is not very prone to produce general peritonitis,
even though there be multiple developments of it. But when the disease
takes the disseminated form, and is sprinkled over the whole extent of
the peritoneum, then inflammation is almost certain to occur--not of
high grade, and yet deserving the name subacute rather than chronic. A
case which illustrates this statement has come under my observation
within the last year. I will recite it with sufficient detail to make
it intelligible.
A lady about forty years of age had, up to the summer of 1881, enjoyed
very good health, though she was never robust. At that time she felt
her strength abating and her stomach disordered. She sought {1169}
health in various places, and took professional advice in September. It
availed her little; the bowels were gradually swelling and fluctuation
could be felt. She was losing strength and flesh. There was not a
cachectic countenance, but the features were growing sharp. She had
suffered but little from pain till October. At that time she was at the
family country home. Then she began to suffer from a severe pain in the
left thigh; and this, it was noticed, increased as the accumulation in
the bowels increased, and at length her physician felt compelled to tap
her--not so much on account of great distension of the bowel as in the
hope of relieving the pain. He drew off nine quarts of gluey, viscid
fluid, and her pain was wholly relieved. Twelve or fifteen days after
this she was brought to her city home, and her city physician, seeing
that her case was a grave one, sought the aid of a distinguished
gynæcologist. She was then again tapped to give him a more satisfactory
examination. He found the ovaries considerably enlarged and hard. They
could not, however, be felt by pressing the fingers into the pelvis
from above--only by the vagina. I saw her on the 10th of November. The
fluid had again made considerable tumefaction of the bowels, and she
was again suffering great pain in the region of the right kidney and in
the leg of the same side, together with cramps. The relief given by the
first tapping induced us to propose its repetition. It was, however,
delayed till the 14th, that the physician who had tapped her before
might be present and assist. The quantity of water drawn was again nine
quarts, and again the pains and spasms were quieted. The examination of
the abdominal fluid was interesting. It was nearly clear, reddish, of
syrupy flow and consistence, and so viscid that while a portion of it
had remained on the slide of the microscope long enough for the
examination of its constituents the thin cover became so firmly
attached to the slide that it could not be removed without breaking or
long maceration. The albumen was so abundant that the fluid was
completely consolidated on boiling. Fibrinous threads were running
through it in great numbers, and here and there was a cell of large
size, round, granular, but not plumped up with granules, with a nucleus
barely less in size than the cell itself; its outer border within, but
only just within, the boundary or wall of the cell. It was the nucleus
that was granular, for there was little room for granules between the
nucleus and the cell wall. The vial containing the fluid had been
standing three or four hours for a sediment. This in a vial four inches
high occupied the lower half, and gave nothing to the dropping-tube
till the sedimentary matter was drawn into it by suction. This matter
consisted of fibrillated fibrin in large quantity; a great number of
the cells just described, some grouped, but most separate or single.
There were pus-cells in moderate quantity, each having the amoeboid
movements, and a considerable number of red blood-corpuscles, some of
natural form, some crenate.
Immediately after the tapping the flaccid condition of the abdominal
walls admitted an examination. A solid, hard mass was found running
across the upper part of the bowels, a nodule of which was lying on the
stomach at the point of the ensiform cartilage. A harder mass of
irregular shape was also found just above the pelvis on the right side,
extending upward and to the right. This was in extent two by three
inches. The ovary, however, could not be detected by pressure from
above {1170} downward. The diagnosis up to this time was hardly
doubtful, but these revelations made it complete, and crushed any
lingering hope of the patient's recovery.
While the pain and spasm ceased after the tapping, the oedema of the
left leg, which came on some time before the last tapping, did not
diminish. The hard spot near the right iliac fossa was tender on
pressure, but otherwise hardly painful. While the fluid did not exceed
six quarts or so, she had little pain anywhere. There were no external
glandular swellings. Her appetite was poor, and she took but little
food. She vomited very little till the end was approaching. The urine
contained a few globules of pus, some pigment matter, two or three
hyaline casts, but no trace of albumen. For sixteen days following
November 14th the patient was comfortable, but the fluid was slowly
filling the bowels again. At that time the pains already referred to
began to return. On December 5th they required another tapping, and
preparations were made for it, but vomiting, rather severe, led to its
postponement to the next day. The quantity of fluid drawn was nine and
a half quarts. It was of the same syrupy consistence as that previously
drawn, and under the microscope showed exactly the same constituents
and gave the same quantity of albumen. The next day stercoraceous
vomiting commenced, with no movement of the bowels, except what was
produced by 10 grains of calomel given on the second day of this
vomiting. That acted well and produced a temporary relief. She after
this took no food by the mouth, but milk and beef-tea were injected
into the rectum. Still, the fecal vomiting returned, and she died on
the 15th.
The post-mortem examination was made on the 17th by William H. Welch. I
could not attend it. His report is complete as to the main features of
the case, though it does not furnish an explanation of the spasms and
the oedema of the left leg, regarding which Welch was not informed. The
pain and spasm were doubtless due to backward pressure of a diseased
part on a nerve or nerves, and the oedema to a narrowing of the iliac
vein by pressure or constriction by fibro-cancerous matter on its outer
sides. "The peritoneal cavity," he says, "contained somewhat over a
gallon of clear, yellow serum. Both the visceral and parietal layers of
the peritoneum were thickened, in some places more than in others; this
was especially marked on the anterior of the stomach and on the lower
part of the ileum and in the left iliac region. The omentum was greatly
thickened and retracted into a firm mass (or roll), which extended
somewhat obliquely across the body, more to the left than to the right.
The mesentery was much thickened and contracted, drawing the intestines
backward. In a few places only was the peritoneal surface coated with
fibrin, and the intestines were mostly free from adhesions. The coils
of the lower part of the ileum, however, were firmly matted together by
organized connective tissue in such a way that they were twisted, often
at a sharp angle, so as greatly to constrict the calibre of the gut.
The serous and muscular layers of the intestine at this point were
greatly thickened. By these causes there appeared to be a complete
obstruction at a point about six inches above the ileo-cæcal valve. By
careful dissection these coils were straightened out, so as to remove
the main cause of obstruction. The peritoneal covering of the liver was
adherent to the parietal layer.
{1171} "The surface of both the visceral and parietal peritoneum was
studded over with hundreds of small, firm, whitish nodules, generally
not larger than a pea, and often not larger than a pin's head. In some
places they had coalesced and made firm patches an inch in extent. This
same material was found in the contracted omentum in considerable
quantity. In a few places, particularly on the uterus, a blackish
pigmented deposit appeared.
"The ovaries were not adherent, but both were enlarged to the size of a
hen's egg. The outer surface of each was rough and corrugated. The new
growth was deposited on the exterior and penetrated each a quarter to
half an inch. It was of uniform white color and of firm consistence.
"The stomach wall was thickened nearly throughout its extent, but
particularly in the anterior part, where it amounted to thrice the
normal thickness. This consisted wholly of hypertrophy of the muscular
coat and increase of fibrous tissue in the peritoneal layer. This new
growth was traced, in the interlacing bands, from the surface into the
muscular coat. In the outer layer of the stomach were found three small
white nodules. The mucous membrane of the organ was healthy or a little
pale.
"The retro-peritoneal glands along the aorta were enlarged, soft, and
of a reddish-gray color. A nodule was found in the wall of the duodenum
outside the mucous membrane, and one in the Fallopian tube."
Every organ in the abdomen and chest was examined, but nothing
important found except what is here recorded. Welch concludes his
record with the following diagnosis: "Primary scirrhous carcinoma of
the ovaries. Secondary deposits in the peritoneum, in the outer layer
of the right Fallopian tube, of the stomach and duodenum, and in the
retro-peritoneal glands. Chronic peritonitis, intestinal obstruction."