1911 Encyclopædia Britannica/Peritonitis
PERITONITIS, inflammation of the peritoneum—the serous membrane which lines the abdominal and pelvic cavities and gives a covering to their viscera. It may exist in an acute or a chronic form, and may be either localized or diffused.
Acute peritonitis may be brought on, like other inflammations, by exposure to wet or cold, or in connexion with injury to, or disease of, some abdominal organ, or with general feebleness of health. It is an occasional result of hernia and of obstruction of the bowels, of wounds penetrating the abdomen, of the perforation of viscera, as in ulcer of the stomach, and of the intestine in typhoid fever, of the bursting of abscesses or cysts into the abdominal cavity, and also of the extensions of inflammatory action from some abdominal or pelvic organ, such as the appendix, the uterus, or bladder. At first localized, it may afterwards become general. The changes effected in the peritoneum are similar to those undergone by other serous membranes when inflamed. Thus, there are congestion; exudation of lymph in greater or less abundance, at first greyish and soft, thereafter yellow, becoming tough and causing the folds of the intestine to adhere together; effusion of fluid, either clear, turbid, bloody or purulent. The tough, plastic lymph connecting adjacent folds of intestine is sometimes drawn out like spun-glass by the movements of the intestines, forming bands and loops through or beneath which a piece of bowel may become fatally snared.
The symptoms of acute peritonitis usually begin by a shivering fit or rigor, together with vomiting, and with pain in the abdomen of a peculiarly severe and sickening character, accompanied with extreme tenderness, so that pressure, even of the bed-clothes, causes aggravation of suffering. The patient lies on the back with the knees drawn up so as to relax the abdominal muscles; the breathing becomes rapid and shallow, and is performed by movements of the chest only, the abdominal muscles remaining quiescent—unlike what takes place in healthy respiration. The abdomen becomes swollen by flatulent distension of the intestines, which increases the distress. There is usually constipation. The skin is hot, although there may be perspiration; the pulse is small, hard and wiry; the urine is scanty and high coloured, and is passed with pain. The face is pinched and anxious. These symptoms may pass off in a day or two; if they do not the case is apt to go on to a fatal termination. In such event the abdomen becomes more distended; hiccough, and the vomiting of brown or blood-coloured matter occur; the temperature falls, the face becomes cold and clammy; the pulse is exceedingly rapid and feeble, and death takes place from collapse, the mental faculties remaining clear till the close. When the peritonitis is due to perforation—as may happen in the case of gastric ulcer or of ulcers of typhoid fever, or in the giving way of a loop of strangulated bowel—the above-mentioned symptoms and the fatal collapse may all take place in from twelve to twenty-four hours. The puerperal form of this disease, which comes on within a day or two after childbirth, is often rapidly fatal. The actual cause of death is the absorption of the poisonous inflammatory products which have been poured out into the peritoneal cavity, as well as of the toxic fluids which have remained stagnant in the paralysed bowel.
Perhaps the commonest cause of septic peritonitis is the escape of micro-organisms (bacillus coli) from the ulcerated, mortified or inflamed appendix (see Appendicitis). A generation or so ago deaths from this cause were generally placed under the single heading of “peritonitis,” but at the present time the primary disease is shown upon the certificate which too often runs thus: appendicitis five days, acute peritonitis two days.
Chronic peritonitis may occur as a result of the acute attack, or as a tuberculous disease. In the former case, the gravest symptoms having subsided, some abdominal pain continues, and there is considerable swelling of the abdomen, corresponding to a thickening of the peritoneum, and to the presence of fluid in the peritoneal cavity. This kind of peritonitis may also develop slowly without there having been any preceding acute attack. There is a gradual loss of strength and flesh. The disease is essentially a chronic one; it is not usually fatal.
Tuberculous peritonitis occurs either alone or in association with tuberculous disease of a joint or of the lungs. The chief symptoms are abdominal discomfort, or pain, and distension of the bowels. The patient may suffer from either constipation or diarrhoea, or each alternately. Along with these local manifestations there may exist the usual phenomena of tuberculous disease, viz. high fever, with rapid emaciation and loss of strength. But some cases of tuberculous peritonitis present symptoms which are not only obscure, but actually misleading. There may be no abdominal distension, and no pain or tenderness. The patient may lie quietly in bed, flat on his back, with the legs down straight, and he may have no marked elevation of temperature. There may be no vomiting and no constipation or diarrhoea. In some cases, the neighbouring coils of intestine having been glued together, a collection of serous fluid takes its place in the midst of the mass, and, being walled in by the adhesions, forms a rounded tumour, dull on percussion, but not tender or painful. Such cases, especially when occurring in women, are apt to be mistaken for cystic disease of the ovary.
As regards the treatment of acute peritonitis, the first thing that the surgeon has to do is to assure himself that the disease is not due to some cause which itself should be dealt with, to a septic disease of appendix or Fallopian tube, for instance, or to a toxic condition of the uterus, the result, perhaps, of a criminal or innocent abortion, or to a perforated ulcer of stomach or intestine. In many obscure cases the safest treatment is likely to be afforded by an exploratory abdominal section. If the medical attendant has made up his mind that the question of exploration is not to be entertained—a decision which should be arrived at only after most deliberate consultation—the best thing will be to apply fomentations to the abdomen, and to administer small and repeated doses of morphia by the skin—18 or 14 grain—repeated every hour or so until the physiological effect is produced. As regards other drugs, it may be a question as to whether calomel or Epsom salts should be given. As regards food, the only thing that can be safely recommended is a little hot water taken in sips. A bed-cradle should be placed over the patient in order to keep the weight of the bed-clothes from the abdomen. (E. O.*)